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A  MANUAL 


Practice  of  Medicine 


PREPARED 


ESPECIALLY   FOR   STUDENTS 


BY 

A»  A.  STEVENS,  A,M.,  M.D. 

PROFESSOR  OF  THERAPEUTICS  AND  CLINICAL  MEDICINE  IN  THE  WOMAN's  MEDICAL  COLLEGE     OF 
PENNSYLVANIA;     LECTURER    ON    PHYSICAL    DIAGNOSIS     IN    THE    UNIVERSITY    OF    PENN- 
SYLVANIA;    PHYSICIAN   TO    THE  EPISCOPAL    HOSPITAL    AND      TO     ST.  AGNES  S 
HOSPITAL  ;   ASSISTANT    PHYSICIAN  TO  THE     PHILADELPHIA     HOSPITAL; 
FELLOW  OF  THE  COLLEGE  OF  PHYSICIANS  OF  PHILADELPHIA,  CtC. 


"  is  an  arch  where  through 

Gleams  that  untravelled  world  whose  margin  fades 
Forever  and  forever  as  we  move." 


EIGHTH    EDITION,    REVISED 

irilustjateb 


PHILADELP  IIA  AND  LONDON 

W.   B,   SAUNDERS   COMPANY 

J908 


Set  up,  electrotyped,   printed,  and   copyrighted    November,  1892.     Reprinted   July,  1893. 
Revised,  reprinted,  and  recopyrighted  September,  1894.     Revised,  reprinted,  and  re- 
copyrighted  August,  1896.     Revised,  reprinted,  and  recopyrighted  October,  1898. 
Reprinted    May,    1899.      Revised,   reprinted,    and    recopyrighted    June,    1900. 
Reprinted  ]May,i9oi.      Revised,  entirely  reset,  electrotyped,  reprinted,  and 
recopyrighted    August,    1903.      Reprinted    April,    1904.     Revised,    re- 
printed,   and    recopyrighted    July,    1905.     Reprinted    June,    1906. 
Revised,  reprinted,  and  recopyrighted  September,   1907. 


Copyright,  1907,  by  W.  B.  Saunders  Company. 


Reprinted  October.  1^08, 


PRINTED    IN    AMERICA 


PRESS    OF 

W.    B.    SAUNDERS    COMPANY 

PHILADELPHIA 


PREFACE  TO  THE  EIGHTH   EDITION. 


In  the  preparation  of  a  new  edition  of  this  Manual  the 
author's  endeavor  has  been  to  bring  the  entire  contents  up 
to  date.  Not  only  has  the  text  been  thoroughly  revised, 
but  much  new  material  has  been  introduced,  and  many 
articles,  especially  in  the  section  dealing  with  Diseases  of 
the  Nervous  System,  have  been  rewritten. 

It  is  hoped  that  in  its  present  form  the  work  may  still 
be  considered  as  affording  a  concise,  but  clear  and  accu- 
rate, representation  of  the  essential  facts  of  the  Practice  of 

Medicine. 

A.  A.  S. 


PREFACE  TO  THE   FIRST   EDITION, 


Pope  says,  *'  Half  our  knowledge  we  must  snatch,  not 
take."  If  this  be  true  of  general  knowledge,  it  is  certainly 
true  of  the  knowledge  of  medicine  as  it  is  taught  in  the 
schools  of  to-day.  In  view  of  this  fact,  there  seems  to  be 
a  real  need  for  books  which  present  their  subjects  in  an 
assimilable  form. 

At  the  request  of  many  students  the  author  has  written 
this  book  with  the  hope  that  it  may  serve  as  an  outline  of 
Practice  of  Medicine,  which  shall  be  enlarged  upon  by  dili- 
gent attendance  upon  lectures  and  critical  observation  at 
the  bedside. 


CONTENTS. 


Diseases  of  the  Digestive  System. 

General  Symptomatology —  page 

The  Teeth  and  Gums 17 

The  Tongue 17 

Discoloration  of  the  Tongue 18 

Tremor  of  the  Tongue       18 

Fissures  on  the  Tongue 19 

Scars  on  the  Tongue 19 

Fetor  of  the  Breath 19 

The  Appetite      ....             19 

Dysphagia '9 

Vomiting,  or  Emesis 20 

The  Vomit 20 

Examination  of  the  Gastric  Contents       21 

Acidity  of  the  Gasiric  Contents 25 

Rumination,  or  Merycismus 25 

Hiccup        25 

Abdominal  Pain  and  Tenderness 26 

The  Stools      26 

Abdominal  Distention 27 

Diseases  of  the  Mouth,  Tonsils,  Pharynx,  and  Esophagus — 

Stomatitis 28 

Catarrhal  Stomatitis 28 

Aphthous  Stomatitis 28 

Ulcerative  Stomatitis 29 

Parasitic  Stomatitis 29 

Gangrenous  Stomatitis       30 

Mercurial  Stomatitis 3^ 

Acute  Tonsillitis 31 

Hypertrophy  of  the  Tonsils 34 

Pharyngitis 35 

Acute  Pharyngitis 35 

Angina  Ludovici 3^ 

Chronic  Pharyngitis , 3^ 

Retropharyngeal  Abscess Zl 

Stenosis  of  the  Esophagus 38 

Spasm  of  the  Esophagus 2,^ 

Organic  Esophageal  Obstruction 38 

3 


4  CONTENTS. 

Diseases  of  the  Stomach —              .  page 

Acute  Gastritis , 39 

Chronic  Gastritis 41 

Atony  of  the  Stomach 45 

Nervous  Dyspepsia 46 

Hyperchlorhydria ,    .    .    .  48 

Gastrosuccorrhea 49 

Gastralgia 50 

Peptic  Ulcer 52 

Cancer  of  the  Stomach      . 56 

Dilatation  of  the  Stomach , 58 

Gastroptosis  and  Enteroptosis .  61 

Hematemesis ..    =    ......  62 

Diseases  of  the  Intestines — 

Habitual  Constipation       ,..    =    ..,  63 

Intestinal  Colic .  65 

Diarrhea 66 

Intestinal  Catarrh      67 

Acute  Ileocolitis 71 

Cholera  Infantum 72 

Dysentery 73 

Cholera  Morbus 77 

Appendicitis 78 

Intestinal  Obstruction 81 

Animal  Parasites , 84 

Cestodes,  or  Tape-worms 84 

Nematodes,  or  Round-worms 85 

Diseases  of  the  Pancreas — 

Hemorrhage  into  the  Pancreas 88 

Acute  Pancreatitis 89 

Chronic  Pancreatitis      . 90 

Cancer  of  the  Pancreas 90 

Cysts  of  the  Pancreas 9I 

Pancreatic  Calculi 92 

Diseases  of  the  Liver — 

Area  of  Liver  Dulness 92 

Palpation  of  the  Liver , 92 

Percussion  of  the  Liver 93 

Jaundice,  or  Icterus 94 

Icterus  Neonatorum 95 

Cholemia 95 

CataiThal  Jaundice , 96 

Acute  Cholecystitis        97 

Cholelithiasis    .... 98 

Hyperemia  of  the  Liver loi 

Cirrhosis  of  the  Liver 102 

Atrophic  Cirrhosis 103 

Hypertrophic  Cirrhosis 105 

Other  Forms  of  Cirrhosis  of  Liver " 106 

Abscess  of  Liver 107 

Cancer  of  the  Liver 108 


CONTENTS.  5 

Diseases  of  the  Liver  {Continued') —  page 

Hydatid  Cyst  of  the  Liver 109 

Amyloid  Liver no 

Acute  Yellov^  Atrophy  of  the  Liver in 

Diseases  of  the  Peritoneum — 

Acute  Peritonitis 112 

Chronic  Diffuse  Peritonitis 114 

Ascites 115 


Diseases  of  the  Kidneys. 

General  Symptomatology — 

The  Urine ^..118 

Polyuria 118 

Anuria 118 

Urea 118 

Lithuria      II9 

Urates 120 

Leucinuria  and  Tyrosinuria 120 

Phosphatm'ia 121 

Chlorids 122 

Oxaluria 122 

Tube-casts 123 

Urobilinuria 124 

Hematoporphyrinuria 124 

Glycosuria 124 

Albuminuria       126 

Acetonuria 127 

Diaceturia  and  Oxybutyria  . 127 

Hematuria 127 

Hemoglobinuria 128 

Indicanuria 128 

Choluria 129 

Chyluria     ,    .    , 129 

Pyuria 129 

Ehrlich's  Diazo-reaction       129 

Diseases  of  the  Kidneys  and  Pelvis  of  the  Kidney — 

Floating  Kidney 130 

Hyperemia  of  the  Kidneys 131 

Uremia 132 

Acute  Nephritis 133 

Chronic  Parenchymatous  Nephritis 135 

Chronic  Interstitial  Nephritis 137 

Amyloid  Degeneration  of  the  Kidney -139 

Pyelitis       139 

Nephrolithiasis 14I 

Hydronephrosis 143 

Tuberculosis  of  the  Kidney ^    .  144 


O  CONTENTS. 

Diseases  of  the  Blood  and  the  Ductless  Glands. 

General  Symptomatology —  page 

Normal  Blood 145 

Examination  of  the  Blood 145 

Plethora .  151 

Hydremia 151 

Anhydremia       ,151 

Melanemia 151 

Polycythemia 151 

Microcytosis  and  Macrocytosis 152 

Poikilocytosis     .    .    .    .    , 152 

Nucleated  Red  Cells 152 

Leukocytosis 152 

Eosinophilia 153 

Leukopenia,  or  Hypoleukocytosis ;    .  153 

Lipemia      153 

i  Blood  Parasites 153 

Oligochromemia 153 

01igoc3rthemia 154 

Anemia^  Addison's  DiseasCj  Exophthalmic  Goiter,  and  Myxedema — 

Anemia  .    „    .    «    ,    »    .    .    .    ,    , 154 

Secondary  Anemia    .0.0.,.    c    ......    , 155 

Primary  Anenua    .    =    «.    c    =    ...    c    .    =    .,....„..    .  155 

Pernicious  Anemia    ..«.    e.    c    ...    .,....»    ...    .  155 

Chlorosis    ......    ».<;.....    =    c    .    c    .»    c    o    ..    .  157 

Leukemia      .    .    .    .  0  .,    ^    o    .    .    .    c    .    .    .    .    c    <    .    c    c    .    .    .    .  158 

Hodgkin's  Disease    ....,...„    c    ..«.    o    .....    .  160 

Splenic  Anemia , 160 

Chronic  Splenomegalic  Polycythemia 161 

Addison's  Disease 161 

Exophthalmic  Goiter .,.»......  162 

Myxedema .,.<...  163 


Diseases  of  the  Circulatory  System. 

General  Symptomatology — 

The  Apex-beat 165 

Displacement  of  the  Apex-beat 166 

Changes  in  the  Force  and  Extent  of  the  Apex-beat 1 66 

Abnormal  Centers  of  Pulsation 166 

Precordial  Prominence • 167 

Palpation 168 

Percussion 168 

Auscultation       168 

The  Intensity  of  the  Heart-sounds 169 

Alteration  in  the  Rhythm  of  the  Heart-sounds 169 

Adventitious  Sounds,  or  Murmurs 170 

Pericardial  Friction-sound 170 

Pleuropericardial  Friction-sound 170 

Cardiorespiratory  Muimur 170 


CONTENTS.  7 

General  Symptomatology  ( Continued )  —  page 

Aneurysmal  Murmur,  or  Bruit 171 

Hemic  Murmurs 171 

The  Pulse 171 

Palpitation      175 

Dropsy 175 

General  Cyanosis 175 

Diseases  of  the  Pericardium — 

Pericarditis 176 

Hydropericardium 179 

Hemopericardium 179 

Pneumopericardium 179 

Diseases  of  the  Pleart — 

Endocarditis 179 

Chronic  Valvular  Disease 182 

Period  of  Compensation 182 

Aortic  Stenosis,  or  Aortic  Obstruction 182 

Aortic  Insufficiency,  or  Aortic  Regurgitation •     ...  183 

Mitral  Stenosis,  or  Mitral  Obstruction 184 

Mitral  Insufficiency,  or  Mitral  Regurgitation 185 

Tricuspid  Stenosis,  or  Tricuspid  Obstruction 186 

Tricuspid  Insufficiency,  or  Tricuspid  Regurgitation 186 

Pulmonary  Stenosis,  or  Pulmonary  Obstruction 186 

Pulmonary  Insufficiency,  or  Pulmonary  Regurgitation 186 

Period  of  Broken  Compensation       186 

Enlargement  of  the  Heart 189 

Acute  Myocarditis     .    „ 190 

Chronic  Myocardial  Disease    .    .    ,    , 191 

Fatty  Infiltration  of  the  Heart     .    .    , < 191 

Fatty  Degeneration  of  the  Heart     .....,.,,..,...  191 

Fibroid  Induration „    ...    c    ..,,.,,...    .  191 

Angina  Pectoris .>..,,,,,,...  193 

Aneurysm  of  the  Aorta    .,..,-,.„,..,.,....  194 

Thoracic  Aneurysm  ...,...,.,.. ,    .  195 

Aneurysm  of  the  Abdominal  Aorta     ,,,..    c    .>....,  197 

Arteriosclerosis      .........    =    ..,    r    ,,..,..    .  197 

Diseases  of  the  Respiratory  System. 

General  Symptomatology — 

Movement  of  the  Alse  Nasi  during  Respuration     -    ; 199 

Nasal  Discharge 199 

The  Sense  of  Smell 199 

Epistaxis 200 

Spasm  of  the  Laryngeal  Adductors 200 

Aphonia,  or  Loss  of  Voice 200 

Dyspnea 200 

Number  of  Respirations  per  Minute 2CI 

Cheyne-Stokes  or  Tidal-wave  Breathing 201 

Cough 202 

Expectoration 202 


8  CONTENTS. 

General  Symptomatology  {^Continued) —  page 

Physical  Examination  of  the  Respiratory  Organs      205 

Inspection  of  the  Chest 205 

Phthisinoid  Chest 205 

Rachitic  Chest 205 

Emphysematous  Chest 206 

Local  Prominences  and  Depressions 206 

Expansion 207 

Litten's  Diaphragm  Phenomenon 207 

Palpation .    .    , 207 

Percussion 208 

Auscultation 210 

Mensuration 214 

Radioscopy 214 

Diseases  of  the  Nose  and  Larynx — 

Coryza '  215 

Chronic  Nasal  Catarrh 216 

Acute  Catarrhal  Laryngitis 218 

Spasmodic  Croup 219 

INIembranous  Croup 221 

Chronic  Laryngitis 221 

Laryngismus  Stridulus      223 

Edema  of  the  Larynx 224 

Diseases  of  the  Lungs — 

Bronchitis       225 

Acute  Catarrhal  Bronchitis 225 

Chronic  Bronchitis 228 

Fibrinous  Bronchitis 231 

Bronchiectasis 232 

Asthma       233 

Essential  Asthma 233 

Hay  Asthma , 236 

Pulmonary  Emphysema 237 

Hypertrophic  Emphysema 238 

Hemoptysis 240 

Hemorrhagic  Infarct  of  the  Lung 241 

Congestion  of  the  Lungs 242 

Hypostatic  Congestion  of  the  Lungs 243 

Edema  of  the  Lungs     . 244 

Croupous  Pneumonia ....  245 

Catarrhal  Pneumonia 250 

Chronic  Interstitial  Pneumonia 255 

Abscess  of  the  Lung 256 

Gangrene  of  the  Lung 256 

Pulmonary  Tuberculosis 257 

Diseases  of  the  Pleura — 

Pleurisy 265 

Empyema       ...    .    ,- 269 

Hydrothorax      270 

Pneumothorax 270 

Hemothorax       272 


CONTENTS.  9 

Acute  Infectious  Diseases.  page 

Fever      .    .    . ..    =    ..... 273 

Period  of  Incubation     .        ..................  276 

Date  at  which  Rashes  Appear 277 

Protection  from  Future  Attacks   ................0277 

Termination  by  Crisis 278 

Infections  in  which  Jaundice  is  Likely  to  Occur 27^ 

Subnormal  Temperature  ...................  278 

Simple  Continued  Fever .  278 

Typhoid  Fever  ...........    =    ...........  279 

Typhus  Fever ..........  287 

Relapsing  Fever =    .    .    .  289 

Cerebrospinal  Fever      .    .    ..................  2qi 

Malarial  Fever  ...............    °    o    .....    .  294 

Intermittent  Malarial  Fever     .................  297 

Estivo-autumnal  Fever 297 

Pei'nicious  Malarial  Fever    ................  298 

Chronic  Malarial  Cachexia  ....        298 

Scarlet  Fever     .......................  301 

Measles 305 

Rubella  .......    ...................  308 

Smallpox ^    ........    .  308 

Vaccinia •    .  313 

Varicella     ......        ..................  314 

Diphtheria ...................315 

Erysipelas .  319 

Influenza 322 

Mumps 324 

Yellow  Fever 325 

Acute  General  Tuberculosis     ......  ^.    .. 327 

Whooping-cough 329 

Cholera 331 

Tetanus 335 

Dengue  ................    .  336 

Hydrophobia ."    ......    .  337 


Constitutional  Diseases. 

Rheumatic  Fever 339 

Chronic  Articular  Rheumatism 343 

Other  Manifestations  of  Rheumatism 344 

Gout 346 

Rheumatoid  Arthritis 350 

Rickets 352 

Diabetes 353 

Diabetes  Insipidus 357- 

Scurvy 358 

Hemophilia 359 

Purpura  Haemorrhagica 360 


10  CONTENTS. 

Diseases  of  the  Nervous  Systkm. 

Disturbances  of  Motion.  page 

Paralysis -  361 

Irregular  Paralysis 361 

Monoplegia 362 

Hemiplegia 362 

Paraplegia 363 

Convulsions 364 

Epileptiform  Convulsions         .    .    .  ' 364 

Tetanic  Convulsions 365 

Hy steroidal  Convulsions 365 

Local  Convulsions , 365 

Saltatory  Spasm 366 

Salaam  Convulsions o    ,    .    . 366 

Choreiform  Movements 366 

Athetosis 367 

Tremors      .........................  367 

The  Gait 368 

The  Reflexes 368 

Disturbances  of  Sensation. 

Anesthesia 370 

Hemianesthesia 370 

Monanesthesia 371 

Paranesthesia 371 

Thermo-anesthesia 0    ....  371 

Analgesia 371 

Astereognosis 371 

Retardation  of  Sensations .  37 1 

The  Sense  of  Space 372 

Hyperesthesia 372 

Paresthesia 372 

Neuralgia 372 

Causalgia • Sl^ 

Pressure  Sense       . 373 

Muscular  Sense      . 3TZ 

Disturbances  of  Nutrition. 

Muscular  Atrophy 373 

Changes  in  Electromuscular  Contractility 373 

Arthropathies „    .  374 

Ulceration  Resulting  from  Perverted  Nutrition 374 

Disturbances  of  Consciousness. 

Coma 375 

Trance 376 

Somnambulism 376 

Ecstasy 376 

Catalepsy o  376 


CONTENTS.  1 1 

Disturbances  of  the  Special  Senses.  page 

The  Eye ,  377 

The  Ear 378 

Psychic  Disturbances. 

Delusion 378 

Illusion       .................    c    ......    .  379 

Hallucination 379 

Imperative  Conceptions 379 

Morbid  Impulse     ....        .................  379 

Delirium 379 


Diseases  of  the  Brain,  Cord,  Nerves,  and  Muscles, 

Acute  Cerebral  Leptomeningitis 380 

Chronic  Cerebral  Leptomeningitis  .....    j_ 382 

Chronic  Cerebral  Pachymeningitis 383 

Hemorrhagic  Pachymeningitis 383 

Chronic  Hydrocephalus 384 

Paretic  Dementia ' 385 

Cerebral  Paralysis  in  Children     . 387 

Cerebral  Hyperemia 388 

Cerebral  Anemia 389 

Cerebral  Hemorrhage 390 

Obstruction  of  the  Cerebral  Arteries 395 

Morbid  Growths  in  the  Brain 396 

Abscess  of  the  Brain 400 

Aphasia 401 

Spinal  Leptomeningitis 403 

Chronic  Spinal  Pachymeningitis 404 

Acute  Myelitis       405 

Chronic  Myelitis 408 

Acute  Anterior  Poliomyelitis =_   .  409 

Chronic  Anterior  Poliomyelitis 41^ 

Primary  Spnstic  Paraplegia 413 

Amyotrophic  Lateral  Sclerosis 414 

Bulbar  Paralysis 414 

Acute  Ascending  Paralysis 415 

Locomotor  Ataxia 4^6 

Ataxic  Paraplegia 4^9 

Disseminated  Cerebrospinal  Sclerosis 420 

Hereditary  Ataxia 421 

Syringomyelia 421 

Caisson  Disease 422 

Diseases  of  the  Nerves — 

Neuritis 423 

Multiple  Neuritis 425 

Sciatica       • »  426 

Facial  Paralysis 427 


12  CONTENTS. 

» 

Functional  Nervous  Diseases —  page 

Headache , ,    .  429 

Vertigo 433 

Meniere's  D  sease 434 

Epilepsy 435 

Hysteria 439 

Neurasthenia 442 

Acute  Chorea „ 444 

Neuralgia 446 

Migraine 450 

Paralysis  Agitans 451 

Artisans'  Cramp 453 

Writers'  Cramp 453 

Tetany 454 

Thomsen's  Disease 455 

Raynaud's  Disease 455 

Acute  Angioneurotic  Edema 456 

Trophic  Disorders,  Sunstroke,  and  Intoxications — 

Muscular  Dystrophies       457 

Facial  Hemiatrophy 458 

Acromegaly 459 

Sunstroke 460 

Alcoholism 461 

Chronic  Opium  Poisoning 464 

Chronic  Lead-poisoning 464 

Diseases  of  the  Skin  and  its  Appendages. 

General  Symptomatology — 

The  Color  of  the  Skin 466 

Hardness  or  Induration  of  the  Skin 467 

Glossy  Skin    .    .    . 467 

Enlargement  of  the  Superficial  Veins 468 

Caput  Medusae 468 

Cutaneous  Emphysema 468 

Abnormal  Conditions  of  the  Nails 468 

Atrophy  of  the  Nails 468 

Curving  of  the  Nails 468 

Onychia 469 

Cutaneous  Eruptions — 

Macules ...    .  469 

Diffuse  Erythema  or  Inflammation  of  the  Skin 471 

Vesicles 472 

Blebs  or  Bullae 473 

Pustules 474 

Papules 475 

Tubercles •. 476 

Wheals  or  Pomphi '  .    .• 477 

•  Crusts 478 

Scales 478 

Ulcers 479 


CONTENTS.  1 3 

Diseases  of  the  Sweat-glands —  page 

Anidrosis    .........    , .  480 

Hyperidrosis  . ,.,..,, ,    .  ^go 

Bromidrosis ,    ,    ,    o    .    .    .    . a%\ 

Chromidrosis      .....,,,,.    =    ,    o.,    o    „    ......  ^gi 

Sudamen » 482 

Functional  Diseases  of  the  Sebaceous  Glands — 

Seborrhea 482 

Comedo 484 

Milium .....,,..    o  48  r 

Steatoma ,..,...........,.,..  A%r 

Inflammatory  Diseases  of  the  Skin — 

Erythema  Simplex ^^86 

Erythema  Intertrigo 486 

Erythema  Nodosum .,....,,.....  487 

Erythema  Multiforme 487 

Urticaria 488 

Urticaria  Pigmentosa .  489 

Herpes  Simplex 489 

Herpes  Zoster 400 

Herpes  Iris     .    . 491 

Acne 491 

Acne  Rosacea 493 

Furunculus 494 

Carbunculus 494 

Psoriasis 495 

Eczema 497 

Lichen  Ruber,  Lichen  Planus,  and  Lichen  Sciofulosis 500 

Prurigo 500 

Dermatitis  Herpetiformis      ..................  501 

Dermatitis 502 

Ecthyma 504 

Pemphigus 505 

Impetigo  Contagiosa 506 

Miliaria 507 

Atrophic  Affections  of  the  Skin — 

Albinism 508 

Vitiligo   . 508 

Atrophic  Affections  of  the  Hair  and  Nails-^ 

Canities  . 509 

Atrophy  of  the  Skin 509 

Atrophy  of  the  Hair 509 

Atrophy  of  the  Nails 510 

Alopecia .....,,... 510 

Alopecia  Areata 511 

Sycosis o 512 

Hypertrophic  Affections  of  the  Skin — 

Pompholyx -    •  5^3 

Lentigo 514 

Chloasma 5^4 

Keratosis  Pilaris       5^5 


1 4  CONTENTS. 

Hypertrophic  Affections  of  the  Skin  {^Continued) —  page 

Molhiscum  Epithehale      ..    =    o    .,......,,,    c    =    =    ,  515 

Callositas    .,.....„,.,.„„....„,    ^    »    .0.  516 
Clavus     ....o.,....,„,..,,,,,,oo.„5i7 

Cornu  Cutaneum    ...,„,..    0    =    0,    ..,    =    .,„o..  517 

Verruca       ..,,    o..,    o    .»    .0    ,,,...,.,<,.    ,.  518 

Nasvus  PigmentosLis  ,,„.,,.,.    .0.    ,,0    =    ,,,,,0  518 
Ichthyosis       ...    =    ..,...,.,.    „o    =    o    ,,,    „ 

Hypertrophic  Affections  of  the  Hair  and  Nails  .    .    „    »    =    =    =    =    ,    .  519 

Onychauxis    ....„„... .o.c..    =    o..5i9 

Hypertrichosis  ............    o    .»    =    =    ..    =    ..    .  520 

Scleroderma       .....,..,.„..    co    =    ..    =    0    = 

Morphea     ..    o    =    .-..    =    .    00    ..,„.    =    =    =    .    .c.    .  520 

Elephantiasis      ..,.    .0    .-.,...,.,......    .  521 

Dermatolysis       .....,,.    o    .    =    o    =    .»,.».    c 

New  Growths  of  the  Skin — 

Keloid    .....        ......,„„.„,....,, 

Fibroma      ...,,    .„o    „...„„„.„    .0    ...    , 

Angioma     ^    ....,..,.,,.„„,„.    .....»»  523 

Xanthoma  ......,..,    =    „,„.„„.,,.    o    =    .    o  524 

Lupus  Erythematosus    .    o    ».o    c    ........,:...•    »  524 

Lupus  Vulgaris      .    .    =    .    ,    o    .    =    ,    =    o    .     =    o    =    ,    o    c    ,    .    .    .  526 

Syphilis  Cutanea  .........„..,„„,.....    =  527 

Leprosy  .......,,,.,,„..    o    o    ..    .^    c    .0.    .  530 

Epithelioma   .....,„.,,    =    ,..    o    0=,    o    ».    ..o  531 

Ainhum      .......    0,.    =    .0    »,..,,....-    .  532 

Neuroses  of  the  Skin — 

Dermatalgia       .    .0,0    =    0    o    .    o    .<....    =    .    o    =    .    o    .    .  533 

Pruritus       .,.......„..._./........  533 

Parasitic  Affections  of  the  Skm — 

Tinea  Trichophytina     .    ,    =    =>..    =    ...,,,..    c    =    ..    =  534 

Tinea  Tonsurans   ....„„...    o    ,„    ...    ^    ..,..    .  534 

Tinea  Circinata      ,..,    =    0    o    ,...    =    =    ;<>..,-....  535 

Tinea  Sycosis     ....        .    .    .    c    o    ,    .    =    «    .    .    o    .    o    =    .    .    .  536 

Tinea  Versicolor    .    .......=,    o    o    o    =    ...    o    ....    .  536 

Tinea  Favosa     ..    ...„o    ,„.»..    o    c,..-.    . 

Scabies    ..    =    ,....    o    ..    ^    .    0    o    c    ..    o    .    =    o    .    . 

Pediculosis     .    .    .    .    .    .    »    .    „    .    »    .    .    ,    ,    .    a    o    ,    .    c    .. 


519 

519 
520 
520 
520 

521 
522 

522 

523 


537 
538 
539 


Index  .  . 


541 


A  MANUAL 


OF   THE 


PRACTICE  OF  MEDICINE 


DISEASES 


OF   THE 


DIGESTIVE    SYSTEM. 


THE  TEETH  AND  GUMS* 

Delayed  dentition  and  the  eruption  of  badly  formed  teeth 
may  result  from  rickets  or  congenital  syphilis. 

Caries  of  the  teeth  results  from  many  conditions,  notably 
an  unnatural  softness  of  the  teeth,  lack  of  cleanliness,  the 
use  of  certain  drugs,  dyspepsia,  and  diabetes. 

Hutchinson's  Teeth. — The  lateral  incisors  of  the  upper 
jaw  are  pegged,  and  the  central  incisors  of  the  same  jaw 
have  convex  sides  and  crescentic  notches  on  their  cutting- 
edges.  These  peculiarities  indicate  hereditary  syphilis,  and 
are  noted  only  in  the  permanent  teeth. 

A  blue  line  on  the  gums  near  the  insertion  of  the  teeth 
usually  indicates  chronic  lead-poisoning.  Copper-  and 
silver-poisoning  occasionally  produce  similar  lines. 

Spongy,  bleeding  gums  are  often  associated  with  scurvy. 
Swelling  of  the  gums,  with  tenderness  and  salivation,  is 
indicative  of  mercurial  poisoning  (ptyaHsm). 

THE  TONGUE* 

Fur  on  the  Tongue. — This  consists  for  the  most  part  of 
accumulated  epithelial  cells,  particles  of  food,  and  micro- 
organisms, and  occurs  in  a  great  variety  of  diseases,  both 
local  and  general. 

2  17 


1 8  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

A  light,  uniform  coat  is  often  noted  in  health,  particularly 
in  those ^  who  sleep  with  the  mouth  open.  Other  causal 
conditions  are:  (i)  Febrile  diseases.  (2)  Dyspepsia.  (3) 
Catarrhal  conditions  of  the  nose  and  throat.  Very  little 
diagnostic  significance  can  be  attached  to  the  appearance  of 
the  tongue  in  diseases  of  the  stomach. 

Circumscribed  f wring  often  indicates  local  disturbance,  as 
a  jagged  tooth  or  tonsillitis. 

Unilateral  furring  may  result  from  disturbed  innervation, 
as  in  conditions  affecting  the  second  and  third  branches  of 
the  fifth  nerve.  It  has  been  noted  in  neuralgia  of  those 
branches,  and  in  fractures  of  the  skull  involving  the  fora- 
men rotundum. 

The  dry,  brown  and  fissured  tongue  is  noted  in  low  fevers, 
as  typhoid  fever,  typhoid  pneumonia,  typhoid  dysentery. 

A  red,  beefy  tongue  is  noted  in  chronic  wasting  diseases. 
It  is  of  quite  frequent  occurrence  in  dysentery  and  in  diabetes. 

The  ''strawberry  tongue''  is  characterized  by  a  white  fur, 
through  which  project  bright-red  and  prominent  papillae. 
It  is  seen  in  the  early  stage  of  scarlet  fever. 

DISCOLORATION  OF  THE  TONGUE. 

Black  Tongue  [Nigrities). — This  is  a  parasitic  affection  of 
the  tongue,  characterized  by  the  appearance  of  black  patches 
on  the  center  of  the  dorsum,  with  great  prolongation  of  the 
filliform  papillae. 

Bluish-black  discoloration  of  the  tongtie  is  observed  in 
Addison's  disease. 

Leukoplakia  Buccalis. — In  this  condition  there  are  slightly 
elevated,  smooth,  opaque,  whitish  plaques  on  the  lingual 
or  buccal  mucous  membrane.  There  are  no  subjective 
symptoms.  Excessive  smoking  is  a  common  cause.  Syph- 
ilis appears  to  be  a  factor  in  some  cases. 

TREMOR  OF  THE  TONGUE. 

Trembling  of  the  tongue  is  noted  in  many  conditions  ;  it 
is  particularly  marked  in  low  fevers  (typhoid),  in  alcohohsm, 
and  in  paretic  dementia. 


DYSPHAGIA.  .  19 

FISSURES  ON  THE  TONGUE. 

Fissures  on  the  tongue  may  result  from  severe  glossitis, 
syphilis,  carcinoma,  tuberculosis,  or  the  impact  of  a  jagged 
tooth. 

SCARS  ON  THE  TONGUE. 

Scars  on  the  tongue  often  result  from  syphilitic  lesions  or 
from  the  tooth  wounds  of  epilepsy. 

FETOR  OF  THE   BREATH* 

This  is  often  due  to  local  inflammation,  as  chronic  rhinitis, 
tonsillitis,  etc.;  to  the  retention  of  decomposing  food,  to 
caries  of  the  teeth,  to  certain  lung  diseases,  especially  gan- 
grene and  bronchiectasis,  to  dyspepsia,  and  to  the  ingestion 
of  certain  foods  or  drugs. 

THE  APPETITE. 

Bulimia,  or  inordinate  appetite,  is  a  common  symptom  in 
nervous  dyspepsia,  hysteria,  diabetes,  and  in  certain  insan- 
ities, notably  in  paretic  dementia.  It  may  be  due  to  intes- 
tinal  parasites. 

Anorexia,  or  loss  of  appetite,  is  a  symptom  common  to 
many  conditions. 

Pica  is  a  craving  for  unnatural  articles  of  food,  and  is 
noted  particularly  in  chlorosis,  insanity,  and  pregnancy. 

DYSPHAGIA. 

Dysphagia,  or  difficult  swallowing,  may  result  from:  (i) 
Local  inflammation,  especially  tuberculous  ulceration  of  the 
throat  or  larynx.  (2)  Stricture  due  to  the  healing  of  an 
ulcer  (corrosive  poisons,  syphilis,  typhoid  fever).  (3)  Can- 
cer of  the  esophagus.  (4)  Spasm  of  the  esophagus  (hyste- 
ria). (5)  A  foreign  body.  (6)  Pressure  on  the  esophagus 
(aneurysm,  mediastinal  tumor,  enlarged  glands,  pericardial 
effusion).  (7)  Paralysis,  local,  as  in  diphtheric  paralysis  ;  or 
centric,  as  in  bulbar  disease. 


20  DISEASES   OF  THE  DIGESTIVE  SYSTEM. 

VOMITING,  OR  EMESIS* 

etiology. — (i)  Toxic,  from  ptomains,  drugs,  uremia, 
and  the  specific  fevers.  (2)  Centric  disease,  as  cerebral 
tumors  and  meningitis ;  this  type  is  often  unaccompanied 
with  nausea,  and  does  not  relieve  the  associated  headache. 
(3)  Diseases  of  the  stomach,  as  ulcer,  cancer,  dilatation, 
catarrh,  etc.  (4)  Reflex,  as  from  pregnancy,  uterine  or 
ovarian  disease,  irritation  of  the  fauces,  worms,  biliary  cohc, 
etc.  (5)  Intestinal  obstruction  :  this  is  often  fecal.  (6)  Dis- 
turbed cerebral  circulation,  as  in  swinging  and  in  sea-sick- 
ness. (7)  Certain  nervous  affections,  as  hysteria,  migraine. 
(8)  Periodic  vomiting  may  be  in  itself  a  neurosis,  or  may  be 
associated  with  the  gastric  crises  of  locomotor  ataxia.  (9) 
Esophageal  vomiting  results  from  obstruction,  and  the  vomit 
is  alkaline  in  reaction. 

THE  VOMIT. 

Watery  or  mucous  vomit  is  noted  in  chronic  gastritis,  in 
certain  forms  of  nervous  dyspepsia,  in  cerebral  disease, 
and  after  persistent  emesis,  as  in  cholera. 

Bilious  or  greeji  vomit  is  not  diagnostic  of  any  special 
condition ;  it  may  occur  in  any  case  in  which  there  are 
persistent  vomiting  and  retching. 

Bloody  Vomit  {Hematemesis). — For  causes,  see  page  62. 
When  present  in  large  amount,  the  blood  can  usually  be 
recognized  by  the  unaided  eye ;  small  amounts  may  be 
detected  by  the  microscope,  by  the  spectroscope,  or  by 
chemical  tests. 

Test  for  Blood. — Evaporate  some  of  the  filtered  coffee- 
grounds  vomit  in  a  watch-glass,  scrape  off  some  of  the  dried 
material ;  add  a  trace  of  finely  pulverized  salt ;  place  the 
mixture  on  an  object-glass,  and  cover.  Allow  one  or  two 
drops  of  glacial  acetic  acid  to  run  under,  and  again  evapo- 
rate ;  when  dry,  allow  one  or  two  drops  of  distilled  water 
to  flow  under  to  dissolve  the  crystals  of  salt.  Under  the 
microscope  brown  rhombic  crystals  of  hematin  appear. 

Purulent  vomit x^^.y  result  from  the  rupture  of  an  abscess 


EXAMINATION  OF  THE    GASTRIC  CONTENTS,         21 

into  the  esophagus  or  stomach  or  from  phlegmonous  gas- 
tritis. 

Fecal  vomit  {stercoraceous  vomit)  indicates  intestinal  ob- 
struction or  a  gastro-coHc  fistula,  the  result  of  ulcer  or 
cancer.     It  is  recognized  by  its  odor  and  appearance. 

Profuse  Vomit. — The  ejection  of  large  quantities  of  frothy 
fermented  material  is  highly  significant  of  gastric  dilatation. 

Vomiting  withoiit  nausea,  distress,  or  other  gastric  phe- 
nomena occurs  in  certain  neuroses  of  the  stomach,  in 
hysteria,  uremia,  and  in  brain  disease,  as  tumor  or  as  a 
precursor  of  apoplexy. 

EXAMINATION  OF  THE  GASTRIC  CONTENTS* 

The  test-breakfast  of  Ewald  and  Boas  consists  of  a  roll 
and  from  lo  to  14  fluidounces  of  water  or  weak  tea.  It  is 
given  in  the  morning  on  an  empty  stomach,  and  is  removed 
in  one  hour  by  aspiration  or  expression.  The  roll  should 
be  thoroughly  masticated.  This  breakfast  affords  the  most 
satisfactory  means  of  determining  the  secretory  activity  of 
the  stomach.  Riegel's  test-meal,  however,  is  better  adapted 
to  determining  the  total  functional  activity  of  the  stomach. 
It  consists  of  a  plate  of  meat-broth,  a  beef-steak  weighing 
from  5  to  7  ounces,  \\  ounces  of  mashed  potatoes,  and  a 
roll.  The  contents  are  removed  in  three  or  four  hours  after 
the  ingestion  of  the  meal. 

Test  for  Free  Acids. — Filter-paper  soaked  in  a  solu- 
tion of  Congo-red  and  dried  turns  blue  in  the  presence  of 
free  acids.  A  saturated  alcoholic  solution  of  tropeolin  00 
turns  from  a  brownish  yellow  to  a  dark  brown  when 
brought  in  contact  with  fluids  containing  free  acids. 

Qualitative  Tests  for  HCl.— Gunzburg's  phloroglu- 
cin-vanillin  test  will  react  with  i  part  of  HCl  in  15,000 
parts  of  water.  The  solution  consists  of  2  parts  of  phloro- 
glucin,  I  part  of  vaniUin,  and  30  parts  of  absolute  alcohol. 
When  a  few  drops  of  this  solution  are  heated  with  an  equal 
quantity  of  the  filtrate  contained  in  a  porcelain  dish,  a  beau- 
tiful red  color  appears  at  the  margin  of  the  fluid.  Boas 
states  that  the  test  is  still  more  delicate  when  1 00  parts  of 
80  per  cent,  alcohol  are  substituted  for  the  30  parts  of 
absolute  alcohol. 


22  DISEASES   OF   THE  DIGESTIVE   SYSTEM. 

Boas'  resorcin-sugar  test  gives  a  similar  reaction.  The 
reagent  consists  of  5  parts  of  resorcin,  3  parts  of  sugar, 
and  100  parts  of  diluted  alcohol. 

Total  Acidity. — This  is  determined  by  allowing  a  deci- 
normal  alkali  solution  (water,  10  c.c. ;  potassium  hydrate, 
56  mg.)  to  flow  from  a  buret,  drop  by  drop,  into  a  beaker 
containing  10  c.c.  of  filtered  gastric  juice,  to  which  have 
been  added  as  an  indicator  tw^o  drops  of  a  i  per  cent,  alco- 
holic solution  of  phenolphthalein.  The  test  is  completed 
when  the  red  color  produced  no  longer  disappears  on  shak- 
ing the  solution.  Ten  c.c.  of  normal  gastric  juice  usually 
require  from  4  to  6.5  c.c.  of  the  standard  alkali  solution. 

Since  i  c.c.  of  the  alkali  solution  is  equivalent  to  0.00364 
gram  of  HCl,  it  follows  that  the  percentage  of  the  latter  in 
a  given  specimen  will  equal  the  number  of  cubic  centimeters 
of  the  alkaU  solution  required  multiplied  by  10,  and  again 
by  0.00364. 

Quantitative  Test  for  Free  Hydrochloric  Acid. — 
Mintz's  Color  Method. — To  10  c.c.  of  the  filtrate  add  a  deci- 
normal  solution  of  sodium  hydrate  from  a  buret  until  a 
droplet  (removed  with  a  platinum  loop)  of  the  fluid  no 
longer  reacts  with  Giinzburg's  reagent.  The  number  of 
cubic  centimeters  of  the  alkaline  solution  used,  multiplied 
by  10  and  then  by  0.00364,  gives  the  percentage  of  free 
hydrochloric  acid.  This  method,  which  is  sufficiently  accu- 
rate for  cHnical  purposes,  is  based  upon  the  supposition 
that  the  alkaK  first  unites  with  the  free  acid  before  it  affects 
the  acid  in  organic  combinations. 

Test  for  lyactic  Acid. — The  presence  of  lactic  acid  in 
the  stomach-contents  simply  indicates  the  existence  of  sub- 
acidity  and  of  stagnation.  These  two  conditions  are  never 
so  constantly  present  nor  so  intense  as  in  carcinoma  (Riegel). 
When  free  HCl  is  present  in  sufficient  quantities,  it  is  unnec- 
essary to  test  for  lactic  acid. 

Uffelmann  recommends  a  mixture  of  10  c.c.  of  a  4  per 
cent,  carbolic  acid  solution  and  20  c.c.  of  distilled  water,  to 
which  is  added  one  drop  of  the  official  liquor  ferri  chloridi. 
This  makes  a  clear  amethyst-blue  solution.  The  reagent 
must   always  be  prepared   at  the   time  of  making  the  test. 


EXAMINATION  OF   THE    GASTRIC   CONTENTS.         23 

If  the  solution  turns  yellowish  green  on  the  addition  of  fil- 
tered gastric  contents,  the  presence  of  lactic  acid  is  demon- 
strated. As  the  blue  serves  only  as  a  contrast  color,  a  very 
dilute  solution  of  iron  chlorid  alone  (one  drop  of  liquor  ferri 
chloridi  in  50  c.c.  of  distilled  water)  suffices.  As  other  sub- 
stances, such  as  sugar,  alcohol,  acid  phosphates,  etc.,  give  a 
somewhat  similar  reaction,  the  test  is  made  more  reliable 
by  exhausting  the  gastric  filtrate  with  pure  ether  (10  vol.), 
evaporating  the  ether,  and  adding  the  reagent  to  an  aqueous 
solution  of  the  residue. 

Test  for  Acetic  Acid. — This  acid  may  be  detected  by 
its  odor.  The  production  of  a  blood-red  color  on  the 
addition  of  a  neutral  solution  of  ferric  chlorid  to  an  aqueous 
solution  of  the  ethereal  extract,  which  has  been  neutralized 
with  sodium  carbonate,  also  indicates  the  presence  of  acetic 
acid. 

Test  for  Butyric  Acid. — This  acid  strikes  a  brownish- 
yellow  color  with  Uffelmann's  reagent.  Its  odor  is  also 
characteristic. 

Tests  for  Rennet  and  Rennet  Zymogen. — Rennet. 
— Add  5  c.c.  of  filtrate,  which  has  been  exactly  neutralized 
with  a  decinormal  alkaline  solution,  to  an  equal  quantity  of 
neutral  raw  or  boiled  milk,  and  keep  the  mixture  at  a  tem- 
perature of  about  100°  F.  If  a  flocculent  coagulate  forms 
in  from  ten  to  thirty  minutes,  the  presence  of  rennet  is 
revealed. 

Rennet  Zymogen. — Render  5  c.c.  of  filtrate  very  slightly 
alkaline  with  a  i  per  cent,  solution  of  sodium  bicarbonate, 
add  about  2  c.c.  of  a  i  per  cent,  solution  of  calcium  chlorid, 
then  mix  with  an  equal  quantity  of  pure  milk,  and  keep  the 
mixture  at  a  temperature  of  100°  F.  If  zymogen  is  present, 
coagulation  occurs  in  the  usual  time. 

Test  for  Pepsin. — If  free  hydrochloric  acid  is  present, 
the  presence  of  pepsin  in  sufficient  quantities  may  be  as- 
sumed. To  determine  the  presence  of  pepsin,  pour  10 
c.c.  of  filtrate  into  a  test-tube.  If  free  HCl  is  absent,  add 
a  sufficient  quantity  of  acid  to  cause  the  appearance  of 
the  Congo  reaction.  Drop  discs  (1.5  mm.  thick  and  10  mm. 
in  diameter)  of  hard-boiled  ^g%  into  the  mixture,  and  put 


24  DISEASES   OF  THE  DIGESTIVE   SYSTEM. 

the  test-tube  into  the  thermostat  at  ioo°  F.  If  sufficient 
pepsin  is  present,  the  discs  will  be  completely  dissolved  in 
from  one-half  to  one  hour. 

Test  for  Carbohydrates. — When  starch  digestion  is 
arrested  too  early,  as  in  cases  of  excessive  secretion  of  HCl, 
Lugol's  solution  gives  a  blue  or  purple  coloration  with  the 
gastric  contents.  Complete  absence  of  color  reaction  indi- 
cates very  active  starch  digestion  (subacidity). 

The  Absorptive  Power  of  the  Stomach. — This  is 
usually  determined  by  the  time  required  for  free  iodin  to 
'  appear  in  the  saliva  after  the  ingestion  of  potassium  iodid. 
The  saliva  is  received  on  filter-paper  impregnated  with 
starch,  a  drop  or  two  of  fuming  nitric  acid  is  then  added, 
and  the  appearance  of  a  blue  color  proclaims  the  presence 
of  iodin.  Normally  the  saliva  should  yield  the  reaction 
for  iodin  in  from  ten  to  fifteen  minutes  after  the  ingestion 
of  a  capsule  containing  o.i  gram  of  potassium  iodid.  Care 
must  be  taken  that  none  of  the  drug  adheres  to  the  outside 
of  the  capsule.  This  test  cannot  be  regarded  as  being  very 
reliable. 

The  Motor  Power  of  the  Stomach. — Ewald  has 
suggested  the  use  of  salol,  which  escapes  from  the  stomach 
into  the  intestine,  where  it  is  broken  up  into  salicylic  acid 
and  phenol.  Normally  salicyluric  acid  appears  in  the  urine 
in  from  forty  to  seventy-five  minutes  after  the  ingestion  of  i 
gram  of  salol.  Filter-paper  moistened  with  urine  containing 
salicyluric  acid  assumes  a  violet  color  when  treated  with  a 
ID  per  cent,  ferric  chlorid  solution. 

Riegel's  test  is  more  reliable.  If  it  is  found  that  seven 
hours  after  a  test-meal  of  broth,  beef-steak,  mashed  pota- 
toes, and  a  roll  (see  p.  21)  much  food  is  still  left  in  the 
stomach,  the  motor  power  is  reduced. 

No  remains  of  the  test-breakfast  should  be  found  after 
two  hours. 

If  much  water  is  recovered  in  one  and  one-half  hours 
after  the  ingestion  of  500  c.c.  of  cool  water,  there  is  motor 
insufficiency,  probably  the  result  of  muscular  weakness,  and 
not  retention  from  pyloric  obstruction. 


HICCUP.  25 

ACIDITY  OF  THE  GASTRIC  CONTENTS- 

Normal  acidity  is  due  to  hydrochloric  acid,  but  other 
acids  are  frequently  formed  during  the  digestive  process, 
such  as  lactic,  butyric,  and  acetic  acids.  The  quantity  of 
hydrochloric  acid  in  normal  gastric  juice  varies  from  0.14 
to  0.2  per  cent.,  more  acid  being  secreted  after  a  heavy  meal 
than  after  a  light  one. 

Hyperacidity  (hyperchlorhydria)  results  from  a 
variety  of  causes.  Early  life,  the  nervous  temperament, 
mental  overexertion,  and  the  persistent  use  of  highly  sea- 
soned foods  are  general  predisposing  factors.  It  is  fre- 
quently present  in  neurasthenia  and  in  hysteria.  It  may 
attend  the  gastric  crises  of  locomotor  ataxia.  It  may  result 
from  the  abuse  of  tobacco.  It  is  present,  as  a  rule,  in  ulcer 
of  the  stomach.  It  is  a  common  symptom  in  chlorosis.  It 
sometimes  occurs  in  cholelithiasis  and  in  nephrolithiasis. 

Subacidity  and  Anacidity  (Hypochylia  Gastrica 
and  Achylia  Gastrica). — Decreased  secretion  of  gastric 
juice  is  seen  in  chronic  gastritis;  in  gastric  cancer;  in 
atrophy  of  the  gastric  tubules ;  in  passive  congestion  of  the 
stomach ;  often  in  febrile  diseases  ;  often  in  severe  anemia ; 
and  in  certain  neuroses,  as  neurasthenia,  hysteria,  and  some 
forms  of  nervous  dyspepsia. 

RUMINATION,  OR  MERYCISMUS. 

Rumination  is  a  condition,  rarely  observed  in  man,  in 
which  the  food  is  regurgitated  from  the  stomach  and  sub- 
jected to  a  second  mastication.  It  is  the  result  of  a  neurosis, 
and  is  generally  found  in  association  with  hysteria,  epilepsy, 
neurasthenia,  or  idiocy.  It  is  sometimes  hereditary  or 
acquired  by  imitation. 

HICCUR 

Hiccup,  or  singultus,  results  from  a  clonic  spasm  of  the 
diaphragm,  and  is  often  noted  as  a  temporary  condition  after 
eating  or  drinking.  Persistent  hiccup  is  sometimes  present 
in  extreme  exhaustion  following  acute  or  chronic  diseases. 
It  may  also  result  from  irritation  of  the  phrenic  nerve,  as 


26  DISEASES   OE   THE   DIGESTIVE   SYSTEM. 

from  the  pressure  of  a  thoracic  aneurysm.  It  may  be  reflex 
from  stomachic,  hepatic,  intestinal,  or  peritoneal  disease.  It 
may  be  due  to  hysteria. 

ABDOMINAL  PAIN  AND  TENDERNESS. 

Diffuse  abdominal  tenderness  is  noted  in  peritonitis,  in 
hysteria,  and  in  rheumatism  of  the  abdominal  muscles. 

Persistent  abdominal  pain  results  from  the  various  visceral 
diseases,  chronic  peritonitis,  abdominal  aneurysm,  and  dis- 
ease of  the  spinal  vertebrae. 

Colic  is  a  painful  spasm  of  a  mucous  canal.  The  chief 
varieties  are  biliary,  intestinal,  renal,  and  pancreatic. 

Painful  defecation  results  from  constipation,  anal  fissure, 
dysentery,  piles,  ulceration,  stricture,  prolapse  of  the  rectum, 
and  inflammatory  conditions  of  neighboring  organs,  as  the 
uterus  or  prostate  gland. 

THE  STOOLS. 

Blood  in  the  Stools  {Entrorrhagia  or  Melend). — The  blood 
is  nearly  normal  in  appearance  after  profuse  hemorrhages, 
or  when  it  has  been  quickly  discharged,  as  in  piles  and 
fissure.  Retained  blood  imparts  a  black  or  tarry  appear- 
ance to  the  stools. 

Helena  results  from  :  (i)  Traumatism;  (2)  acute  inflam- 
mation of  the  bowels,  as  in  enteritis  and  dysentery ;  (3) 
passive  congestion,  as  in  chronic  heart  and  liver  disease  ;  (4) 
vicarious  menstruation  (extremely  rare) ;  (5)  blood  dyscrasia, 
as  in  scurvy,  purpura,  infectious  fevers,  etc. ;  (6)  rupture  of 
an  aneurysm  ;  (7)  ulcers  in  the  intestines,  as  simple  duodenal 
ulcers,  typhoid,  dysenteric,  tubercular,  or  malignant  ulcers; 
(8)  intussusception  ;  (9)  the  passage  of  blood  from  the 
stomach  in  hematemesis ;  (10)  hemorrhagic  infarction  of 
the  bowel  from  embolism  or  thrombosis  of  the  mesenteric 
artery;  (11)  piles,  fissure,  fistula. 

Watery  or  serous  stools  are  noted  in  choleraic  diseases,  in 
nervous  diarrhea,  in  the  colliquative  diarrhea  which  termi- 


ABDOMINAL   DISTENTION.  2 J 

nates  wasting  diseases,  in  severe  enteritis,  and  in  corrosive 
poisoning,  as  by  arsenic  or  antimony. 

Green  stools  may  result  from  an  excessive  amount  of  bile. 
They  are  also  common  in  the  diarrheas  of  young  children, 
as  a  result  of  the  abnormal  decomposition  of  the  bile  pig- 
ment. 

Black  stools  follow  intestinal  hemorrhage  and  the  use 
of  certain  drugs,  as  charcoal,  bismuth,  iron,  tannin,  etc. 

Reel  stools  usually  indicate  blood,  but  they  may  be  tinged 
red  after  the  administration  of  hematoxylin  (logwood). 

Mucous  stools  are  noted  in  intestinal  catarrh,  particularly 
when  the  lower  bowel  is  affected,  as  in  enterocoHtis  and 
dysentery. 

Fatty  stools  result  from  the  ingestion  of  large  quantities 
of  fats,  from  the  absence  of  bile,  and  from  chronic  pancre- 
atic diseases. 

Purnlent  stools  result  from  fistula  in  ano,  dysenteric,  syph- 
ilitic, or  malignant  ulceration,  or  the  rupture  of  abscesses 
into  the  bowel,  as  prostatic  and  pelvic  abscesses. 

Lieiiteric  stools,  those  which  contain  much  undigested  food, 
are  noted  in  inflammatory  conditions  of  the  stomach  and 
upper  bowel. 

ABDOMINAL  DISTENTION. 

Causes. — (i)  Enlargement  of  the  various  organs  from 
tumors  or  other  causes.  Recognized  by  the  history,  irregu- 
lar enlargement,  and  special  symptoms  referable  to  the 
organ  affected.  (2)  Ascites.  Recognized  by  movable  dul- 
ness  with  superincumbent  tympany,  and  fluctuation.  (3) 
Chronic  peritonitis  (tuberculous  or  cancerous)  with  effusion. 
Recognized  by  the  history,  progressive  emaciation,  presence 
of  a  primary  lesion  elsewhere,  and  detection  of  tumor-like 
masses,  with,  perhaps,  pain  and  tenderness.  (4)  Tympanites. 
Recognized  by  universal  tympany  on  percussion.  (5)  Preg- 
nancy. Recognized  by  suppression  of  menses,  morning 
emesis,  pigmentation  of  mammary  areola,  softening  of  the 
cervix,   intermittent  uterine    contractions,  etc.     (6)  Disten- 


28  DISEASES   OF  THE  DIGESTIVE  SYSTEM. 

tion   of  the  bladder.     Recognized  by  the  history,  location 
of  dulness,  and  results  of  catheterization. 

STOMATITIS. 

Definition. — Inflammation  of  the  mouth. 

etiology. — (i)  Mechanical,  chemical,  thermal,  or  para- 
sitic irritation.  (2)  Mercurial  poisoning.  (3)  Cachectic 
states,  as  in  phthisis,  cancer,  and  diabetes.  (4)  It  is  most 
commonly  seen  in  young  children  in  association  with  gas- 
tro-intestinal  disturbances,  brought  about  by  artificial  feed- 
ing, warm  weather,  and  bad  hygienic  surroundings. 

Varieties. — (i)  Catarrhal.  (2)  Aphthous.  (3)  Ulcera- 
tive. (4)  Parasitic  (thrush).  (5)  Gangrenous.  (6)  Mer- 
curial. 

General  Symptoms. — Heat  and  pain  in  the  mouth,  in- 
creased flow  of  saliva,  fetor  of  the  breath,  restlessness,  lan^ 
guor,  disinchnation  to  nurse,  and  perhaps  some  fever. 

CATARRHAL  STOMATITIS. 
(Simple  Stomatitis.) 

Symptoms. — General  symptoms  of  stomatitis,  and,  on 
inspection,  a  diffuse  red  swelling  of  the  mucous  membrane. 

Treatment. — The  cause  must  be  removed.  Errors  of 
hygiene  should  be  corrected.  The  diet  and  the  state  of  the 
alimentary  tract  should  receive  careful  attention.  The 
mucous  membrane  of  the  mouth  should  be  washed  at  fre- 
quent intervals  with  cool  antiseptic  solutions.  In  mild 
catarrhal  stomatitis  a  solution  of  boric  acid,  5  to  10  grains  to 
the  ounce,  will  suffice.  In  obstinate  cases  the  mouth,  after 
being  carefully  cleansed,  may  be  lightly  painted  with  a  solu- 
tion of  silver  nitrate,  4  grains  to  the  ounce. 

APHTHOUS  STOMATITIS. 

(Follicular  Stomatitis;  Vesicular  Stomatitis.) 

Symptoms. — General  symptoms  of  stomatitis,  and,  on 
inspection,  numerous  small  white  vesicles  on  the  cheeks, 
lips,  and  tongue ;  these  vesicles  soon  break,  and  leave  little 
shallow  ulcers  with  a  red  areola. 


STOMA  TITIS.  29 

Prognosis. — Good. 

Treatment. — The  same  as  for  catarrhal  stomatitis.  The 
following  application  is  useful : 

R.     Acidi  borici .   gr.  x-xx 

Glycerini f^ss 

Aquae q.  s.  ad  fjij. — M. 

ULCERATIVE  STOMATITIS. 

This  is  thought  by  some  to  be  an  infectious  disease,  be- 
cause it  often  occurs  in  epidemics,  and  may  attack  both  chil- 
dren and  adults  when  congregated  and  subjected  to  bad 
hygienic  conditions. 

Symptoms. — General  symptoms  of  stomatitis. 

Inspection. — The  gums  of  the  lower  jaw  are  chiefly 
affected.  They  are  swollen,  red,  and  spongy.  Linear 
ulcers,  with  gray,  sloughing  bases,  soon  form,  and  may 
extend  to  the  cheek.  The  glands  under  the  jaw  are 
swollen.  In  severe  cases  loosening  of  the  teeth  and  necro- 
sis of  the  bone  may  follow. 

Prognosis. — Guardedly  favorable. 

Treatment. — Hygienic  conditions  must  be  improved. 
Potassium  chlorate  is  almost  a  specific.  It  should  be  used 
both  locally  and  internally.  The  dose  for  a  child  of  three 
years  is  from  I  to  3  grains,  well  diluted,  every  three  hours. 
The  ulcers  may  be  painted  with  a  solution  of  silver  nitrate, 
10  grains  to  the  ounce.  Tonics,  like  quinin  and  iron,  are 
called  for  in  some  instances. 

PARASITIC  STOMATITIS. 
(Thrush;  Muguet.) 

Exciting  Cause.— Oidium  albicans. 

Symptoms. — General  symptoms  of  stomatitis,  and,  on  in- 
spection, numerous  milk-white  elevations  which,  on  removal, 
leave  a  raw  surface.  The  disease  may  extend  to  the  phar- 
ynx, esophagus,  and  larynx.  Microscopic  examination  re- 
veals the  fungus. 

Prognosis. — Good. 

Treatment. — Everything  that  comes  in  contact  with  the 


30  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

child's  mouth  should  be  rendered  absolutely  clean.  Gas- 
tro-intestinal  derangements  should  receive  attention.  The 
mouth  should  be  cleansed  at  frequent  intervals,  especially 
after  feeding,  with  one  of  the  following  solutions :  Sodium 
bicarbonate  (i  dram  to  5  ounces);  sodium  hyposulphite  (20 
grains  to  i  ounce) ;  potassium  permanganate  {^  grain  to  i 
ounce). 

GANGRENOUS  STOMATITIS. 
(Cancrum  Oris ;  Noma.) 

This  form  is  seen  most  frequently  in  debilitated  children 
between  the  ages  of  two  and  six  years,  and  usually  follows 
one  of  the  specific  fevers,  especially  measles  and  whooping- 
cough.     It  may  be  a  sequel  to  ulcerative  stomatitis. 

Various  micro-organisms  have  been  isolated,  especially 
the  diphtheria  bacillus  and  a  thread-like  parasite  of  the 
leptothrix  type. 

Symptoms. — The  general  symptoms  of  stomatitis  are 
marked.  The  cheek  is  the  part  usually  affected.^  Exter- 
nally, it  is  swollen,  hard,  red,  and  glazed ;  internally  there 
is  noted  an  irregular,  sloughing  ulcer.  The  putrefaction 
causes  an  intensely  fetid  odor.  The  duration  of  the  disease 
is  from  one  to  three  weeks. 

Complications. — Perforation,  septicemia,  lobular  pneu- 
monia from  aspirated  sloughs,  and  diarrhea  from  the  swal- 
lowing of  fetid  material. 

Prognosis. — Grave.  In  the  large  majority  of  cases  (85 
per  cent.)  the  child  dies  from  exhaustion  or  complications. 
Recovery  is  usually  attended  with  deformity. 

Treatm.eiit.— The  sloughing  surface  and  the  tissue  im- 
mediately surrounding  it  should  be  promptly  destroyed 
under  anesthesia  with  the  actual  cautery  or  strong  nitric 
acid.  After  the  operation  the  mouth  should  be  cleansed  at 
frequent  intervals  with  a  solution  of  hydrogen  dioxid  (1:3) 
or  of  potassium  permanganate  (i  percent.).  Concentrated 
nutritious  food,  stimulants,  and  tonics  are  urgently  indicated. 

*  In  girls  noma  sometimes  attacks  the  vulva. 


ACUTE    TONSILLITIS.  3 1 

MERCURIAL  STOMATITIS. 

(Ptyalism.) 

This  form  of  stomatitis  is  seen  in  artisans  who  work  in 
mercury,  after  the  administration  of  very  large  doses  of 
mercurials,  and  after  the  administration  of  small  doses  when 
there  has  been  an  unnatural  susceptibility. 

Symptoms. — Premonitory  Symptoms. — Tenderness  of  the 
gums,  manifested  by  bringing  the  teeth  forcibly  together ; 
redness  of  the  gums  near  the  insertion  of  the  teeth,  a 
metaUic  taste,  and  an  increase  of  saliva. 

Later  Symptoms. — Profuse  salivation,  fetor  of  breath,  red- 
ness, swelling,  and  tenderness  of  the  gums.  The  tongue 
may  be  similarly  affected  and  protrude  from  the  mouth. 
In  severe  cases  ulceration  of  the  mucous  membrane,  loss  of 
teeth,  and  necrosis  of  the  jaw  result. 

Treatment. — The  administration  of  mercury  should  be 
suspended  as  soon  as  the  slightest  tenderness  of  the  gums 
manifests  itself  The  mouth  should  be  frequently  rinsed 
with  a  saturated  solution  of  potassium  chlorate.  In  severe 
cases  the  affected  parts  may  be  painted  with  slightly  diluted 
sulphurous  acid  or  with  a  saturated  solution  of  iodoform  in 
ether.  To  check  the  excessive  flow  of  saliva,  atropin  {^\^ 
grain)  may  be  given  once  or  twice  a  day.  Morphin  may  be 
required  at  night  to  relieve  pain  and  to  secure  sleep.  Potas- 
sium iodid  is  recommended  to  aid  in  the  elimination  of  the 
mercury.  Tonics  may  be  needed  to  combat  the  anemia 
and  exhaustion. 

ACUTE  TONSILLITIS. 

(Amygdalitis.) 

l^tiology. — Acute  tonsillitis  occurs  at  all  ages,  but  it  is 
particularly  common  in  youth. 

Exposure  to  cold  and  wet  usually  excites  it,  and  such  ex- 
posure is  very  effective  when  the  system  is  debilitated  or 
the  throat  is  congested  from  improper  use  of  the  voice. 
Impure  air,  as  the  effluvium  from  foul  drains  or  sewers, 
apparently  may  cause  it.     As  a  secondary  affection  it  is  of 


32  DISEASES   OF   THE   DIGESTIVE   SYSTEM 

frequent  occurrence  in  acute  infectious  diseases,  as  scarlet 
fever,  diphtheria,  rheumatism,  and  variola.  Streptococci, 
staphylococci,  diphtheria  bacilli,  or  pneumococci  may  be 
found  in  the  exudate. 

Varieties. — (i)  Simple  or  catarrhal.  (2)  Follicular  or 
lacunar.     (3)  Phlegmonous  (quinsy). 

Symptoms. — The  chief  symptoms  are  chilliness,  head- 
ache and  backache,  high  fever  (103°- 1 05°  F.),  pain  in  the 
throat,  difficult  deglutition,  an  altered  nasal  voice,  salivation, 
fetor  of  the  breath,  and  swelling  and  tenderness  behind  the 
angles  of  the  jaw. 

In  the  catarrhal  form  the  tonsils  are  uniformly  swollen, 
red,  and  covered  with  tenacious  mucus. 

In  \h^  follicular  form  the  tonsils  are  red  and  swollen,  and 
present  little  yellow  spots  on  their  surfaces.  These  spots 
correspond  to  collections  of  desquamated  and  degenerated 
epithelial  cells  in  the  lacunae  or  crypts  of  the  gland. 
During  convalescence  the  contents  of  the  lacunae  are  often 
expelled  in  the  form  of  cheesy  pellets  having  a  characteristic 
unpleasant  odor. 

In  the /^/^^;;^<?;/^?^^  form  the  tonsils  are  extremely  swollen — 
often  so  -much  that  they  almost  meet ;  the  pain  is  intense 
and  of  a  throbbing  character.  One  gland  soon  becomes 
larger  than  the  other,  softens,  fluctuates,  and  turns  yellow 
from  suppuration.  Swallowing  is  almost  impossible,  the 
voice  is  lost,  and  breathing  is  difficult. 

Complications. — Albuminuria  is  frequent.  Endocar- 
ditis, otitis  media,  and  a  diffuse  erythema  occasionally 
occur.  Suffocation  from  rupture  into  the  larynx  and  ulcera- 
tion into  the  carotid  artery  are  extremely  rare  terminations. 

Diagnosis. — Follicular  tonsillitis  must  be  distinguished 
from  scarlet  fever  and  diphtheria. 

Scarlet  Fever. — The  early  and  persistent  vomiting,  the  very 
frequent  pulse,  the  "  strawberry  tongue,"  and  the  peculiar 
punctiform  eruption  will  suggest  scarlatina. 

Diphtheria. — In  this  disease  there  is  an  ashy-gray  mem- 
brane, which  cannot  be  readily  detached,  and  which,  if  re- 
moved forcibly,  leaves  a  bleeding  surface.  The  membrane 
does  not  remain  limited  to  the  tonsils,  but  soon  spreads  to 
the  pillars,  uvula,  and  pharynx.     In  doubtful  cases  the  only 


ACUTE    TONSILLITIS.  33 

criterion  is  the  presence  or  absence  of  the  Klebs-Loffler 
bacillus. 

Prognosis. — Favorable ;  accidents  are  very  rare.  The 
duration  varies  from  a  few  days  in  the  mild  catarrhal  form 
to  a  week  or  more  in  the  phlegmonous  form. 

Treatment. — The  patient  should  be  confined  to  a  warm 
room,  and  if  there  be  much  fever,  to  bed.  A  mild  aperient 
is  indicated  at  the  outset.  The  diet  should  be  light  but 
sustaining.  The  sucking  of  ice  affords  rehef  The  most 
reliable  internal  remedies  are  the  salicyhc  compounds  and 
sodium  benzoate.  These  should  be  given  in  full  doses  at 
frequent  intervals. 

^.     Ammonii  salicylatis -    •   3ij 

Syrupi  acacise f^ss 

Aquae  menthse  piperiise    .    .    .    q.  s.  ad  f^iij. — M. 

SiG. — A  teaspoonful  every  three  hours  for  a  child  of  six  years. 

Guaiac  is  also  recommended.  A  dram  of  the  ammoni- 
ated  tincture  of  guaiac  may  be  given  in  milk  every  three 
hours.  Febrile  symptoms,  if  pronounced,  may  be  controlled 
by  small  doses  of  phenacetin  or  by  a  combination  of  aconite 
and  spirit  of  nitrous  ether.  The  pain  may  be  so  intense  as 
to  require  the  use  of  opium. 

Local  Treatment. — Externally,  cold  applications  aid  in 
bringing  about  resolution ;  if,  however,  suppuration  be  in- 
evitable, warm  applications  should  be  employed  to  hasten 
the  process.  Antiseptic  sprays,  like  Dobell's  solution  (see 
p.  37)  or  a  solution  of  hydrogen  dioxid  (i  14),  are  of  de- 
cided benefit.  Direct  applications  to  the  surface  of  the 
glands  of  the  tincture  of  ferric  chlorid,  of  a  saturated  ethe- 
real solution  of  iodoform,  or  of  dry  sodium  carbonate  are 
often  useful. 

K.     Potassii  chloratis gi"-  xx 

Tincturae  ferri  chloridi f^iij 

Glycerini f^vj 

Aquae q.  s.  ad  f^ij. — M. 

SiG. — Use  locally. 

Scarification,  followed  by  gargling  with  hot  water,  is 
another  measure  which  frequently  affords  relief 

Pus  should  be  evacuated  as  soon  as  its  presence  can  be 

3 


34  DISEASES   OF   THE  DIGESTIVE   SYSTEM. 

detected.  In  the  majority  of  cases  it  is  best  to  make  the 
incision  not  in  the  tonsil  itself,  but  in  the  soft  palate,  a  little 
above  and  to  the  outer  side  of  the  gland. 

HYPERTROPHY  OF  THE  TONSILS. 

Etiology. — Hypertrophy  of  the  tonsils  occurs  most  fre- 
quently in  childhood.  While  it  is  often  excited  by  repeated 
attacks  of  tonsillitis,  in  some  cases  there  appears  to  be  no 
other  cause  than  a  congenital  predisposition. 

Pathology. — It  may  be  a  true  hypertrophy,  but  in  most 
instances  either  the  glandular  structure  or  the  connective 
tissue  predominates  ;  the  firmness  of  the  gland  increases  in 
proportion  to  the  overgrowth  of  the  latter.  The  follicles  are 
often  dilated  and  filled  with  cheesy  material  which  results 
from  the  accumulation  of  fatty  degenerated  epithelium. 
Nasopharyngeal  catarrh,  hyperplasia  of  the  lingual  tonsil, 
and  adenoid  growths  in  the  nasophaiynx  are  often  asso- 
ciated conditions. 

Symptoms. — The  symptoms  consist  in  mouth-breath- 
ing, snoring  during  sleep,  difficult  deglutition,  a  thick  voice 
of  a  nasal  quality,  fetor  of  the  breath,  impairment  of  hear- 
ing, a  listless  expression  of  countenance,  mental  dulness, 
and  malnutrition.  Night-terrors  are  common.  Persistent 
interference  with  breathing  through  the  nose  gives  rise  to 
the  following  deformities  :  narrowing  of  the  nostrils,  con- 
traction of  the  superior  dental  arch,  elevation  of  the  hard 
palate,  and,  especially,  a  chest  conformation  Hke  that  of 
rickets  {pigeon-breast). 

Complications. — Hypertrophy  of  the  tonsils  increases 
the  liability  to  acute  catarrh  of  the  nasopharynx,  to  follicular 
tonsillitis,  and  to  diphtheria.  Chronic  catarrh  of  the  middle 
ear,  bronchial  asthma,  and  facial  chorea  are  possible  sequels. 

ProgfllOSiS. — Favorable,  if  proper  treatment  be  adopted. 

Treatment. — Attempts  to  reduce  the  enlargement  by 
applying  tincture  of  iodin,  tincture  of  ferric  chlorid,  alum 
and  glycerin,  etc.,  usually  fail.  When  the  glands  are  very 
large  and  the  general  health  is  suffering,  no  time  should  be 
lost  in  resorting  to  tonsillectomy.  Pharyngeal  adenoids 
should  also  be  removed. 


PHARYNGITIS.  35 

Constitutional  treatment  should  not  be  neglected.  It  in- 
cludes systematic  bathing,  breathing  exercises,  attention  to 
diet  and  clothing,  and  the  administration  of  such  drugs  as 
cod-liver  oil,  hypophosphites,  and  iodid  of  iron. 

PHARYNGITIS. 

ACUTE  PHARYNGITIS. 
(Acute  "  Sore  Throat  "  ;  Simple  Angina.) 

Definition. — An  acute  catarrhal  inflammation  of  the 
mucous  membrane  of  the  pharynx,  soft  palate,  and  uvula. 
It  is  frequently  associated  with  tonsillitis  and  laryngitis. 

l^tiology. — Exposure  to  cold  and  wet  is  the  most  com- 
mon cause.  It  may  be  of  rheumatic  or  gouty  origin.  It 
may  be  excited  by  local  irritants,  such  as  hot  drinks  or  the 
inhalation  of  noxious  gases. 

It  is  also  met  with  in  scarlet  fever,  measles,  and  other 
infectious  fevers. 

Symptoms. — Chilliness,  slight  fever  with  its  associ- 
ated phenomena,  stiffness  and  tenderness  of  the  muscles  of 
the  neck,  soreness  in  the  throat,  painful  deglutition,  a  sen- 
sation of  dryness  or  tickling,  and  a  hacking  cough.  Ex- 
tension to  the  larynx  may  cause  hoarseness ;  to  the  ear, 
through  the  Eustachian  tube,  deafness.  Inspection  reveals 
a  red  and  swollen  mucous  membrane. 

Prognosis. — Favorable. 

Treatment. — In  mild  cases  a  gargle  of  potassium  chlo- 
rate will  suffice.  In  severe  cases  the  application  to  the 
throat  of  cloths  wrung  out  of  cold  water  proves  grateful. 
The  sucking  of  pieces  of  ice  affords  much  relief  Gargles 
or  sprays  of  the  distillate  of  hamamelis  (50  per  cent.)  are 
useful.  A  spray  of  menthol,  2  grains  to  the  ounce  of  liquid 
petrolatum,  is  also  efficacious.  Lozenges  containing  cocain 
will  often  relieve  pain  and  allay  the  tickling  sensation  in  the 
throat.  The  following  formula,  recommended  by  Bosworth, 
answers  the  purpose  admirably  : 

R.     Cocainag  hydrochloridi gi"-  v 

Extracti  kramerise    . gf-  ij 

Sodii  bicarbonatis .    .    .  gr.  xv 

Extracti  glycyrrhizae    ........  ^iiss. — M. 

Fiant  trochisci  No.  xxx. 


36  DISEASES   OF  THE  DIGESTIVE  SYSTEM.    . 

Internally  a  mild  aperient  may  be  given  at  the  outset. 
Sodium  benzoate  (5  grains  four  times  daily)  has  a  beneficial 
effect.  Belladonna  with  aconite  is  also  recommended.  The 
rheumatic  form  usually  yields  promptly  to  a  mild  salicylic 
preparation  hke  salophen  (5  to  8  grains  three  or  four  times 
a  day). 

ANGINA  LUDOVia, 
(Ludwig's   Angina.) 

This  is  a  very  grave  and  rapid  form  of  phlegmonous 
inflammation  of  the  tissues  about  the  floor  of  the  mouth 
and  sides  of  the  neck.  It  may  occur  in  the  course  of 
various  specific  fevers,  or  it  may  be  excited  by  traumatism 
or  carious  processes  at  the  roots  of  the  teeth.  It  may  end 
in  abscess-formation  or  gangrene,  and  frequently  leads  to 
general  septicemia. 

CHRONIC  PHARYNGITIS. 

Ktiology. — Chronic  "  sore  throat "  may  result  from  re- 
peated acute  attacks,  from  overuse  or  improper  use  of  the 
voice,  or  from  the  prolonged  action  of  irritants,  like  tobacco- 
smoke.  It  is  a  frequent  attendant  upon  chronic  nasal 
catarrh  and  indigestion. 

Varieties.— (i)  Hypertrophic;  (2)  atrophic. 

Symptoms. — The  voice  is  husky,  and  its  use  is  followed 
by  distress ;  secretion  is  increased,  so  that  there  is  a  con- 
stant desire  to  clear  the  throat ;  disagreeable  sensations,  as 
fulness,  tickling,  and  the  like,  are  frequently  noted. 

In  the  hypertrophic  form  (granular  sore  throat,  clergy- 
man's sore  throat,  chronic  follicular  pharyngitis)  the  mucous 
membrane  is  thick,  swollen,  traversed  by  dilated  veins,  and 
studded  with  numerous  elevations  which  correspond  to  dis- 
tended follicles  and  overgrown  lymphatic  tissue. 

In  the  atrophic  form  (pharyngitis  sicca)  the  mucous  mem- 
brane is  pale,  smooth,  glossy,  and  dry. 

Treatment. — The  removal  of  the  cause  is  of  prime 
importance.  All  sources  of  local  irritation,  such  as  mis- 
use and  overuse  of  the  voice,  mouth-breathing,  excessive 
smoking,  and  intemperance  in  eating  and  drinking,  must  be 


PHARYNGITIS.  37 

avoided.  Patients  should  be  instructed  to  expel  sounds  by 
the  aid  of  the  diaphragm  and  abdominal  muscles  instead 
of  the  muscles  of  the  throat.  Nasal  obstructions  and  ade- 
noid growths  must  be  removed.  The  habit  of  hawking 
and  scraping  to  clear  the  throat  should  be  rigidly  inter- 
dicted. Digestive  disturbances  should  receive  careful  atten- 
tion. Tonics,  like  iron,  strychnin,  and  cod-liver  oil,  are 
sometimes  required. 

Local  Treatment. — The  nasopharynx  should  be  kept  clean 
by  frequent  spraying  with  an  antiseptic  alkaline  liquid,  like 
Dobell's  solution : 

R ,    Sodii  bicarbonatis 

Sodii  boratis aa  gr.  xv 

Acidi  carbolici gr.  viij 

Glycerini {"T^x] 

Aquae ^5^''']- — ^'^■ 

Astringent  applications  are  often  of  service ;  one  of  the 
following  may  be  employed :  Zinc  sulphate,  5  grains  to  the 
ounce ;  tannin,  i  dram  to  the  ounce  of  glycerin ;  silver 
nitrate,  lo  to  20  grains  to  the  ounce.  In  the  follicular 
variety  it  is  advisable  to  destroy  the  enlarged  follicles  by 
means  of  the  galvanocautery,  after  which  the  astringent 
applications  may  be  made. 

RETROPHARYNGEAL  ABSCESS. 
(Retropharyngeal  Lymphadenitis.) 

This  is  a  suppurative  inflammation  of  the  pharyngeal 
lymphatics,  usually  secondary  to  one  of  the  specific  fevers, 
to  follicular  tonsillitis,  suppurative  rhinitis,  otitis  media,  or 
to  caries  of  the  cervical  vertebrae.  It  occurs  especially 
in  children.  It  may  be  recognized  by  pain  in  the  throat, 
dysphagia,  dyspnea,  alteration  in  the  voice,  and  the  detection, 
on  inspection  or  palpation,  of  a  swelling  projecting  from 
the  posterior  pharyngeal  wall. 

Treatment. — As  soon  as  pus  can  be  detected  it  should 
be  evacuated  by  means  of  a  guarded  bistoury,  the  head  of 
the  child  being  held  forward  to  prevent  the  escape  of  the 
pus  into  the  larynx. 


38  DISEASES   OE   THE   DIGESTIVE   SYSTEM. 

STENOSIS  OF  THE  ESOPHAGUS. 

Varieties. — (i)  Functional  obstruction  due  to  spasm 
(esophagismus).     (2)  Organic  obstruction. 

SPASM  OF  THE  ESOPHAGUS. 
(Esophagismus.) 

!^tiolog"y. — It  usually  occurs  in  women  as  a  manifesta- 
tion of  hysteria.  It  may  occur  as  a  symptom  of  hydro- 
phobia or  of  chorea.  It  may  be  due  to  reflex  irritation 
originating  in  the  esophagus  itself  or  in  some  distant  organ. 

Symptoms  of  Hysteric  Esophagismus. — It  is  mani- 
fested by  paroxysmal  dysphagia,  a  sense  of  constriction  in 
the  chest,  and  sometimes  by  choking  and  the  regurgitation 
of  food. 

Diagnosis. — It  may  be  recognized  by  the  age  and  sex 
of  the  patient,  the  paroxysmxal  character  of  the  obstruction, 
the  ease  with  which  a  bougie  can  be  passed,  the  presence 
of  emotional  disturbances,  the  absence  of  emaciation,  and 
the  absence  of  any  other  obvious  cause. 

Prognosis. — Good. 

Treatment. — The  underlying  neurosis  should  receive 
appropriate  treatment.  The  systematic  passage  of  a  bougie 
often  results  in  a  cure. 

ORGANIC  ESOPHAGEAL  OBSTRUCTION. 

Etiology.  —  (i)  An  external  tumor  pressing  on  the 
esophagus.  This  is  most  commonly  an  aneurysm.  (2)  A 
tumor  growing  from  the  esophageal  wall,  generally  a  can- 
cer. (3)  A  cicatrix  from  ulceration.  The  ulcer  may  be 
due  to  syphilis  or  to  the  ingestion  of  some  corrosive  poison, 
as  a  strong  acid  or  alkali.     (4)  A  foreign  body. 

Symptoms. — The  chief  symptom  is  slowly  increasing 
difficulty  in  deglutition,  with  the  regurgitation  of  food. 
The  esophagus  is  often  much  dilated  above  the  constric- 
tion, and  the  food  may  collect  in  the  pouch  thus  formed, 
so  that  regurgitation  may  be  delayed  for  several  hours. 
The  passage  of  a  bougie  meets  with  a  permanent  obstruc- 
tion.    There  is  much  loss  of  flesh. 


ACUTE    GASTRITIS.  39 

Diagnosis. — The  history  of  syphiHs  or  of  corrosive 
poisoning  will  suggest  a  cicatrix.  Aneurysmal  obstruction 
can  usually  be  detected  by  physical  examination.  Aneurysm 
should  be  excluded  before  a  bougie  is  passed.  The  age, 
cachexia,  pain,  expectoration  of  blood-streaked  mucus,  and 
involvement  of  other   organs  will  indicate  cancer. 

Prognosis. — Depends  on  the  cause.  It  is  unfavorable 
in  aneurysm  and  cancer.  In  cicatricial  contraction  the  ob- 
struction may  be  overcome  for  an  indefinite  period. 

Treatment. — Aneurysm :  Prolonged  rest,  dry  diet, 
potassium  iodid ;  surgical  measures  (Moore-Corradi 
treatment,  see  p.  196).  Cicatricial  contraction:  Systematic 
dilatation  with  graduated  bougies.  Cancer :  In  the  early 
stage,  the  cautious  use  of  a  bougie  is  advisable.  In  ad- 
vanced cases  the  patient  may  be  fed  through  a  tube,  and 
when  this  is  no  longer  possible,  life  may  be  prolonged  for 
a  short  time  by  rectal  alimentation  or  by  feeding  through 
a  gastric  fistula. 

ACUTE  GASTRITIS. 

(Acute  ^Gastric  Catarrh.) 

etiology. — It  may  result  from — (i)  The  ingestion  of 
indigestible  food,  of  partially  decomposed  food,  or  of  exces- 
sive quantities  of  food;  (2)  from  the  ingestion  of  irritant 
poisons — alcohol,  strong  acids,  or  alkalis  ;  (3)  it  accom- 
panies many  of  the  infectious  fevers. 

Pathology. — The  mucous  membrane  is  red,  swollen, 
and  covered  with  thick  mucus.  It  is  sometimes  the  seat  of 
ecchymosis.  The  microscopic  changes  consist  in  marked 
mucoid  degeneration  and  cloudy  swelling  of  the  epithelial 
cells,  and  the  infiltration  of  the  interstitial  tissues  with  round 
cells. 

In  toxic  gastritis  there  is  often  extensive  sloughing  of  the 
gastric  mucosa. 

Symptoms. ^The  symptoms  vary  much  in  degree.  In 
mild  cases  there  are  anorexia,  a  feeling  of  discomfort  and 
fulness,  eructations,  nausea,  and,  perhaps,  vomiting.  The 
tongue  is  heavily  coated.     In  severe  cases  the   symptoms 


40  DISEASES   OF   THE    DIGESTIVE   SYSTEM. 

are  more  marked,  particularly  the  nausea  and  vomiting. 
There  may  be  also  moderate  fever  (102^-103°  F.),  thirst, 
herpes,  distention  of  the  epigastrium,  local  tenderness,  and 
considerable  prostration.  The  vomitus  is  composed  at  first 
of  sour,  fermented  food  ;  later,  of  mucus  and  bile.  Jaundice 
may  follow  from  the  extension  of  the  catarrh  to  the  duode- 
num and  bile-ducts,  and  diarrhea  from  its  extension  to  the 
intestines. 

Toxic  gastritis  is  manifested  by  intense  burning  pain  in  the 
throat,  gullet,  and  stomach,  persistent  vomiting  of  food- 
remnants  mixed  with  blood  and  mucus,  marked  abdominal 
tenderness,  and  the  phenomena  of  collapse. 

Atrophy  of  the  mucosa  and  cicatricial  stenosis  of  the 
orifices  are  common  sequels  in  cases  that  do  not  prove  im- 
mediately fatal. 

Diagnosis. — It  may  resemble  the  onset  of  scarlet  fever, 
but  the  history  of  contagion,  the  "strawberry  tongue,"  sore 
throat,  very  rapid  pulse,  and  eruption  will  lead  to  the  recog- 
nition of  the  latter. 

Prognosis. — Simple  acute  gastritis  runs  a  favorable 
course,  and  rarely  lasts  more  than  a  few  days. 

Treatment. — Absolute  rest  is  essential.  If  the  stomach 
has  not  been  completely  emptied,  an  emetic,  such  as  warm 
water  or  ipecac,  should  be  employed.  Locally,  a  mustard- 
plaster  or  a  turpentine  stupe  will  aid  in  relieving  distress. 
As  a  rule,  no  food  should  be  given  by  the  mouth  until  the 
stomach  becomes  retentive.  Ice,  however,  may  be  allowed 
to  quench  the  thirst.  In  delicate  subjects  nutrient  enemata 
will  be  required.  If  there  is  constipation,  a  mercurial  laxa- 
tive may  be  given  with  advantage.  Such  a  combination  as 
the  following  usually  acts  favorably : 

R.     Hydrargyri  chloridi  mitis gr.  j 

Bismuthi  subnitratis gr.  xx. — M. 

Fiant  chartulae  No.  vj. 

SiG. — One  on  the  tongue  every  hour,  to  be  followed  by  a  Seidlitz 
powder,  if  necessary. 

Severe  pain,  nausea,  restlessness,  and  insomnia  are  best 
relieved  by  opium  suppositories.  Persistent  vomiting  may 
be  relieved  by  bismuth  subnitrate  (10  grains)  combined  with 


CHRONIC   GASTRITIS.  4 1 

creasote   (^  minim),  with  cocain  (|-  grain),  or  with  hydro- 
cyanic acid,  as  in  the  following  formula : 

I^.     Bismuthi  subnitratis ^iij 

Acidi  hydrocyanici  diluti tT\^  xxxij 

Aquse f^iv. — M. 

SiG. — Shake  well.     A  dessertspoonful  every  three  hours. 

The  following  combination  of  ipecac  and  nux  vomica  is 
often  serviceable : 

Jjt.     Tincturge  nucis  vomicae 

Villi  ipecacuanhae aa  f^ij. — M. 

SiG. — Two  drops  every  hour. 

After  the  lapse  of  twenty-four  or  thirty-six  hours  it  is 
generally  possible  to  give  bland  nourishment  by  the  mouth. 
Barley-water,  champagne  with  soda-water,  milk  and  lime- 
water,  peptonized  milk,  and  light  broths  may  be  given  in 
small  quantities  at  frequent  intervals.  The  return  to  solid 
food  should  always  be  carried  out  very  gradually. 

The  treatment  of  toxic  gastritis  consists  in  the  immediate 
neutralization  of  the  poison  by  chemical  antidotes,  in  the 
evacuation  of  the  stomach  (except  in  the  late  stages  of 
poisoning  by  caustics)  by  the  stomach-pump  or  emetics, 
and  in  the  administration  of  demulcents  and  opium. 

CHRONIC  GASTRITIS. 

(Chronic  Gastric  Catarrh ;  Catarrhal  Dyspepsia.) 

!^tiolog^. — It  may  be  excited — (i)  By  prolonged  irrita- 
tion of  the  stomach,  such  as  results  from  errors  in  diet 
(excesses  in  eating  and  drinking,  indigestible  food,  excessive, 
irregular  meals,  deficient  mastication,  etc.)  or  from  the  ex- 
cessive use  of  alcohol,  tobacco,  condiments,  or  purgatives ; 
(2)  by  passive  congestion  the  result  of  chronic  heart  disease 
or  cirrhosis  of  the  liver  ;  (3)  by  chronic  diseases  that  disturb 
metabolism,  such  as  tuberculosis,  diabetes,  chronic  Bright's 
disease,  gout,  chlorosis,  etc. ;  (4)  by-chronic  diseases  of  the 
stomach  itself,  such  as  cancer,  ulcer,  gastrectasis,  etc. 

Patliolog"y. — The  mucous  membrane  is  of  a  grayish  or 
slaty  color,  swollen,  and  covered  with  tenacious  mucus. 
The   veins   are    dilated,   and    there   may  be    ecchymoses. 


42  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

Microscopically,  there  is  a  cellular  infiltration  in  the  inter- 
stitial tissue.  The  glands  are  dilated,  elongated,  and  tortu- 
ous, and  their  epithelium  is  more  or  less  degenerated  and 
detached.  The  interglandular  proliferation  may  be  so  pro- 
nounced as  to  cause  great  thickening  of  the  mucous  mem- 
brane (^hypertrophic  gastritis),  or,  on  the  other  hand,  the 
new-formed  fibrous  tissue  may  contract  to  such  a  degree  as 
to  cause  extreme  thinning  of  the  coats  of  the  stomach  and 
atrophy  or  complete  destruction  of  the  glandular  elements 
(atrophic  gastritis). 

Symptoms.  —  The  subjective  symptoms  are  very  vari- 
able, and,  for  the  most  part,  not  characteristic.  The  chief 
phenomena  are  furring  of  the  tongue,  fetor  of  the  breath, 
anorexia,  fulness  and  distress,  especially  at  the  height  of 
digestion,  belching,  eructations,  heartburn,  constipation, 
headache,  vertigo,  and  attacks  of  palpitation.  Nausea  and 
vomiting  are  not  uncommon.  The  latter  may  occur  before 
breakfast  or  at  the  height  of  digestion.  If  it  occurs  on 
rising  in  the  morning,  the  vomit  consists  of  tough  masses 
of  mucus  ;  if  it  occurs  after  meals,  the  vomit  is  composed 
of  undigested  food  remnants  intimately  mixed  with  more 
or  less  glairy  mucus.  The  entire  epigastrium  may  be  sen- 
sitive to  pressure. 

The  objective  symptoms  are  characteristic.  Examination 
of  the  stomach-contents  reveals  an  excessive  secretion  of 
mucus,  a  marked  reduction  in  the  secretion  of  HCl  ^  and  of 
the  digestive  ferments,  and  imperfect  digestion  of  albumins. 
In  uncomplicated  cases  there  is  no  motor  insufficiency. 

Chronic  gastric  catarrh  rarely  terminates  in  atropine  gas- 
tritis (achylia  gastrica),  the  most  important  symptoms  of 
which  are  paroxysmal  pain,  more  or  less  persistent  vomit- 
ing, constipation  alternating  with  diarrhea,  pronounced 
emaciation  and  anemia,  and  absence  of  free  HCl  and  of 
digestive  ferments  from  the  stomach-contents  after  a  test- 
breakfast. 

Diagnosis. — Atony  of  the  Stomach. — In  simple  atony 
fluids  excite  as  much  distress  as  solids,  vomiting  is  not  com- 
mon, the  secretion  of  mucus  is  not  increased,  the  secretion 
1  In  rare  instances  the  secretion  of  HCl  is  increased. 


CHRONIC   GASTRITIS.  43 

of  HCl  is  not  usually  decreased,  and  considerable  quantities 
of  undigested  food  can  be  recovered  from  the  stomach 
seven  hours  after  a  test-meal. 

Hyper chlorhydria. — In  this  condition  the  general  health  is 
not  impaired,  the  appetite  is  usually  good,  there  is  more  or 
less  severe  pain  shortly  after  eating,  albumins  and  alkalis 
relieve  the  pain,  and  excess  of  HCl  is  found  in  the  stomach- 
contents  ;  albumin-digestion  is  good,  starch-digestion  is  re- 
tarded, and  there  is  no  excess  of  mucus. 

Nervous  Dyspepsia. — In  this  syndrome  the  severity  of  the 
symptoms  varies  considerably  from  day  to  day  according  to 
the  mental  state  of  the  patient,  and  is  not  materially  influ- 
enced by  the  quantity  or  the  quality  of  the  food;  the  gen- 
eral health  is  not  often  impaired,  the  nervous  symptoms  are 
very  prominent,  the  secretion  of  the  stomach  is  usually 
normal,  and  there  is  no  excess  of  mucus. 

Peptic  Ulcer. — The  severe,  localized  paroxysms  of  pain 
shortly  after  eating,  the  locaHzed  tenderness,  hematemesis, 
and  hyperacidity  will  serve  to  distinguish  ulcer  from  catarrh. 

Cancer  of  the  Stomach. — The  history,  rapid  course,  ca- 
chexia, persistent  vomiting,  hematemesis,  palpable  tumor, 
signs  of  gastrectasis,  and  the  early  absence  of  free  HCl  from 
the  gastric  juice,  with  the  presence  of  large  quantities  of 
lactic  acid  and  of  the  Boas-Oppler  bacilli,  will  usually 
render  the  diagnosis  clear. 

Care  must  be  taken  to  determine  whether  the  catarrh  is 
primary  or  secondary  to  some  constitutional  or  visceral 
disease. 

ProgftlOSiS. — The  primary  forms  of  chronic  gastritis, 
when  not  too  far  advanced,  are  frequently  cured.  The 
prognosis  is  unfavorable  when  there  is  much  atrophy  of  the 
gastric  mucosa.  In  the  secondary  forms  the  prognosis  is 
dependent  on  that  of  the  primary  disease. 

Treatment. — The  cause  should  be  ascertained  and  re- 
moved if  possible.  Regularity  in  the  time  of  meals,  slow- 
ness in  eating,  and  thorough  mastication  of  food  must  be 
insisted  upon.  The  patient  should  be  cautioned  against 
overeating  and  the  taking  of  large  quantities  of  liquid,  espe- 
cially of  iced  water,  during  meals.     Overindulgence  in  alco- 


44  DISEASES   OF  THE  DIGESTIVE  SYSTEM. 

hoi,  tobacco,  coffee,  and  tea  should  be  forbidden.  The  re- 
sumption of  mental  or  physical  work  immediately  after 
meals  should  also  be  avoided. 

A  mixed  diet  of  bland,  readily  digestible  food  is  required. 
It  may  usually  include  boiled,  baked,  or  grilled  beef  and 
mutton,  chicken,  sweetbread,  boiled  fish,  oysters,  soft-boiled 
or  poached  eggs,  pulled  bread,  fresh  butter,  baked  potato, 
young  string-beans,  small  peas,  spinach,  hearts  of  celery, 
thoroughly  cooked  cereals,  calves'-foot  jelly,  and  junket. 
Tea,  coffee,  and  cocoa  may  or  may  not  be  permissible. 

An  exclusive  milk  diet  acts  exceedingly  well  in  some 
cases.  Systematic  lavage  is  of  great  value  in  severe  cases, 
especially  when  there  is  excessive  secretion  of  mucus. 
When  lavage  cannot  be  tolerated,  the  stomach  may  be 
cleansed  by  a  glass  of  hot  alkaline  water  slowly  sipped  a 
half-hour  or  more  before  breakfast.  The  following  artificial 
Carlsbad  salt  may  be  used  as  the  alkaH : 

R.     Sodii  sulphatis ^x 

Sodii  bicarbonatis     .........  ^iv 

Sodii  chloridi ,;^ij.^M. 

SiG. — A   teaspoonful   in   a  glass  of  hot  water  an  hour   before 
breakfast. 

In  mild  cases  the  administration  of  a  bitter — calumba, 
gentian,  nux  vomica — some  time  before  meals  often  proves 
efficacious.  In  many  cases  an  alkali  may  be  added  with 
advantage  to  the  bitter,  as  in  the  following  formula : 

R.     Sodii  bicarbonatis     . :^iss 

Infusi  gentianae  compositi f^vj. — M. 

SiG. — A  tablespoonful  before  meals. 

When  the  stomach  is  highly  sensitive,  silver  nitrate  will 
be  found  a  valuable  remedy.  It  may  be  given  in  pill  form 
in  combination  with  hyoscyamus,  as  in  the  following 
formula : 

R.     Argenti  nitratis gr.  vj 

Extracti  hyoscyami gr.  x. — M. 

Fiant  pilulae  No.  xx. 

SiG. — One  pill  a  half-hour  before  meals. 

Bismuth  subnitrate  is  also  of  service  in  such  cases. 
Diluted  hydrochloric  acid  is  sometimes  serviceable  in  re- 


ATONY  OF   THE  STOMACH.  45 

placing  the  natural  acid  of  the  gastric  juice.  In  many 
cases,  however,  better  results  are  secured  from  the  adminis- 
tration, during  meals,  of  pancreatin  with  sodium  bicarbonate. 
Flatulence  and  fermentation  may  be  controlled  by  such 
antiseptics  as  bismuth  salicylate,  creasote,  bismuth-beta- 
naphthol,  etc.     The  following  combination  is  often  of  value. 

R.     Creasoti 11^  xx 

Bismuth-beta-naphthol gr-  c 

Pulveris  zingiberis gr.  xxx. — M. 

Pone  in  capsulas  No.  xx. 

SiG. — One  after  meals. 

So  far  as  possible,  constipation  should  be  overcome  by 
regulation  of  diet,  systematic  exercise,  and  the  use  of 
enemas  or  suppositories. 

Change  of  scene,  a  sunny  cHmate,  good  hours,  and  free- 
dom from  business  worry  and  household  cares  often,  prove 
more  beneficial  than  any  other  measure  employed. 

ATONY  OF  THE  STOMACH. 

(Motor  Insufficiency ;  Myasthenia  Gastrica.) 

Definition. — Atony  of  the  stomach  consists  in  relaxa- 
tion of  the  muscular  coat  of  the  stomach  and  insufficiency 
of  its  propulsive  powers.     It  frequently  leads  to  gastrectasis. 

etiology. — Motor  insufficiency  is  of  common  occur- 
rence. It  may  be  congenital ;  it  may  be  caused  by  intem- 
perance in  eating  and  drinking  ;  it  may  follow  acute  infec- 
tions ;  it  may  occur  in  the  course  of  chronic  diseases 
attended  by  malnutrition ;  it  may  appear  acutely  after 
traumatism  or  intense  emotional  excitement ;  it  may  be  a 
complication  in  other  diseases  of  the  stomach,  especially  in 
gastroptosis,  chronic  gastritis,  nervous  dyspepsia,  and  hyper- 
secretion. 

Symptoms. — In  simple  atony  the  chief  symptoms  are 
a  feeling  of  fulness  and  discomfort  after  meals,  especially  if 
the  latter  have  been  large,  and  frequent  belching  of  gas. 
The  severity  of  the  symptoms  often  bears  a  definite  relation 
to  the  quantity  of  food  taken.  Fluids  are  as  likely  to  excite 
distress  as  sohds.     As  a  rule,  there  is  neither  vomiting  nor 


46  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

pain.  The  appetite  is  usually  good,  the  general  health  is 
not  seriously  affected,  and  the  symptoms  entirely  abate  upon 
the  evacuation  of  the  stomach.  There  are  no  signs  of  gas- 
trectasis.  When  the  intestines  are  similarly  affected,  there 
may  be  marked  nervous  symptoms — headache,  vertigo,  and 
paresthesia — and  considerable  disturbance  of  nutrition. 

The  diagnosis  is  rendered  certain  by  the  recovery  of  a 
considerable  quantity  of  undigested  food  from  the  stomach 
seven  hours  after  the  ingestion  of  the  Riegel  test-meal. 

Prognosis. — Favorable,  if  the  cause  can  be  removed. 

Treatment. — The  first  indication  is  to  remove  the  cause. 
The  food  should  be  readily  digestible,  small  in  bulk,  finely 
divided,  and  nutritious.  Fluids,  except  in  moderate  quan- 
tities, and  coarse  vegetables  are  to  be  avoided.  The  diet  may 
include  tender  meats,  eggs,  oysters,  boiled  fish,  well-cooked 
cereals,  steamed  rice,  stale  bread,  fresh  butter,  baked  pota- 
toes, tender  spinach,  string-beans,  and  asparagus-tips.  It  is 
rarely  necessary  to  increase  the  number  of  meals.  Rest  for 
at  least  an  hour  after  large  meals  is  to  be  urged.  Exercise 
in  the  open  air  and  frequent  tepid  baths  are  general  meas- 
ures of  value.  Lavage  is  unnecessary  unless  there  are 
gastrectasis  and  fermentation. 

General  tonics,  especially  iron,  are  often  needed.  The 
most  useful  direct  remedies  are  the  bitters  (quassia,  gentian, 
and  calumba),  particularly  the  tincture  of  nux  vomica, 
which  may  be  given  in  doses  of  from  5  to  lo  minims,  grad- 
ually increased,  before  meals.  Alkalis  are  indicated  when 
there  is  hypersecretion.  Antifermentatives — bismuth  sali- 
cylate, beta-naphthol-bismuth,  salol,  and  creasote — are  use- 
ful in  reducing  flatulence. 

Constipation  is  best  relieved  by  diet,  abdominal  massage, 
and  enemas. 

NERVOUS  DYSPEPSIA. 

(Neurasthenia  Gastrica.) 

Definition. — The  characteristic  feature  of  this  syndrome 
is  pronounced  discomfort  during  the  period  of  digestion, 
out  of  all  proportion  to  the  disturbances  of  gastric  secre- 


NERVOUS  DYSPEPSIA.  47 

tion  or  motility.  The  source  of  the  discomfort  appears  to 
be  an  excessive  irritabihty  of  the  nerves  of  the  stomach. 

etiology. — Nervous  dyspepsia  usually  occurs  in  those 
of  a  distinctly  nervous  temperament,  and  mental  overexer- 
tion, worry,  and  excesses  are  potent  etiologic  factors.  It  is 
frequently  associated  with  neurasthenia  and  hysteria.  It 
may  be  due  to  reflex  irritation  from  other  organs. 

Symptoms. — The  tongue  is  often  clean.  The  appetite  is 
very  variable — at  one  time  it  is  lost,  at  another  it  is  inordinate, 
at  another  it  is  perverted,  the  patient  craving  unnatural  food. 
Pain  during  the  period  of  digestion  is  a  prominent  symptom. 
It  varies  in  intensity  from  a  feeling  of  discomfort  to  the  most 
violent  distress.  There  is  rarely  tenderness,  but  the  skin 
over  the  stomach  is  often  abnormally  sensitive. 

Belching  is  common.  Vomiting  is  not  frequent.  Exag- 
gerated peristaltic  movements  attended  with  gurgling  sounds 
(peristaltic  unrest)  may  be  perceptible  to  the  patient.  Ner- 
vous phenomena— headache,  vertigo,  disturbed  sleep,  hypo- 
chondriasis, lassitude,  and  palpitation — are  conspicuous. 

Gastric  acidity  is  usually  normal,  but  there  may  be  sub- 
acidity  or  hyperacidity.  In  the  majority  of  cases  gastric 
motility  is  not  affected,  the  viscus  emptying  itself  within  the 
normal  period. 

The  symptoms  are  usually  confined  to  the  period  of 
digestion  ;  they  are  out  of  proportion  to  the  disturbance  of 
the  digestive  functions  ;  they  vary  greatly  from  day  to  day, 
according  to  the  mood  of  the  patient ;  and  they  are  not 
materially  influenced  by  the  quality  or  the  quantity  of  the 
food. 

Prognosis. — Good,  when  the  cause  can  be  removed. 

Treatment. — The  treatment  is  largely  that  of  neur- 
asthenia. The  avoidance  of  excitement  and  of  excessive 
mental  work  must  be  enjoined.  An  extended  voyage  may 
effect  a  cure.  In  brain-workers  systematic  exercise  in  the 
open  air  and  frequent  bathing,  followed  by  friction  of  the 
skin,  often  prove  very  efficacious.  On  the  other  hand,  the 
exhausted  and  anemic  may  demand  the  "  rest-cure."  The 
diet  should  be  bland  and  readily  digestible.  In  many  cases 
milk  is  an   appropriate  food.     Tonics,  hke  iron  and  arsenic, 


48  DISEASES   OF  THE  DIGESTIVE  SYSTEM. 

are  often  indicated.  Short  courses  of  an  unirritating  bromid, 
like  that  of  strontium,  sometimes  do  good  The  following 
combination  of  antispasmodics  is  useful  in  certain  cases : 

R .     Zinci  valeratis ,    .    .  gr.  xxx 

Extract!  sumbul gr.  xx 

Arseni  trioxidi gr.  J 

Extract!  gentia!ise gr.  x. — M. 

Fiant  pilulas  No.  xx. 

SiG. — One  pill  after  each  meal. 

HYPERCHLORHYDRIA. 

(Superacidity;  Hyperacidity.) 

Definition. — These  terms  are  used  to  designate  an 
abnormal  increase  in  the  secretion  of  hydrochloric  acid 
during  the  digestive  act. 

;^tiolog"y. — This,  anomaly  of  secretion  is  most  frequently 
seen  in  neuropathic  subjects  between  the  ages  of  fifteen  and 
forty.  Mental  overexertion,  the  excessive  use  of  tobacco, 
overindulgence  in  condiments,  and  insufficient  mastication 
are  important  predisposing  factors.  It  is  a  common  com- 
plication in  chlorosis,  in  gastric  ulcer,  and  in  cholelithiasis. 

Symptoms. — The  symptoms  do  not  appear  immediately 
after  eating,  but  at  the  acme  of  digestion,  and  include  sen- 
sory irritation,  varying  in  degree  from  slight  discomfort  to 
agonizing  pain,  with  acid  eructations,  heartburn,  thirst,  dif- 
fuse tenderness  over  the  stomach,  and  occasionally  vomit- 
ing. These  symptoms  are  relieved  by  eating  small  quan- 
tities of  albuminous  food  and  by  the  ingestion  of  alkalis,  and 
disappear  spontaneously  upon  evacuation  of  the  stomach. 
They  may  be  continuous  or  periodic. 

The  stomach-contents  obtained  after  a  test-breakfast  are 
excessively  rich  in  hydrochloric  acid,  both  free  and  com- 
bined. Albumin  digestion  is  rapid.  The  resting  stomach 
is  empty.     There  is  no  motor  insufficiency. 

Prognosis. — In  the  absence  of  comphcations  the  prog- 
nosis is  favorable. 

Treatment. — The.  cause  should  be  ascertained  and  re- 
moved, if  possible;  thorough  mastication  is  imperative. 
The  diet  should  be  unirritating,  and  composed  largely  of 
albuminoid  foods.     Coarse  substances,  vinegar,  spices,  con- 


GASTROSUCCORRHEA.  49 

diments,  coffee,  and  alcohol  should  be  avoided.  A  moder- 
ate amount  of  water  or  weak  tea  at  meals  is  desirable. 
Fats,  in  the  form  of  cream  and  butter,  are  usually  well 
borne.  Starchy  foods  should  be  used  sparingly  and  only 
when  thoroughly  cooked.  It  is  sometimes  desirable  to 
increase  the  number  of  meals. 

Alkalis,  in  the  form  of  sodium  bicarbonate  or  magnesia, 
administered  at  the  height  of  digestion,  relieves  the  symp- 
toms. Silver  nitrate  (^  grain)  with  extract  of  belladonna  (^ 
grain)  thrice  daily,  on  an  empty  stomach,  is  useful.  Silver 
nitrate  (i  :  2000  to  i  :  1000)  may  also  be  given  as  a  stomach- 
douche  with  advantage.  As  there  is  often  marked  hyper- 
esthesia of  the  gastric  mucosa  in  these  cases,  sedatives,  like 
bromrds,  valerates,  and  sumbul,  are  sometimes  of  service. 

GASTROSUCCORRHEA. 

(Reichmann's  Disease.) 

Definition. — This  is  a  functional  condition  characterized 
by  the  secretion  of  large  quantities  of  gastric  juice,  even 
when  the  stomach  is  empty.  It  is  often  associated  with 
hyperchlorhydria.  Two  forms  have  been  recognized — (i) 
the  continuous  and  (2)  the  intermittent. 

l^tiolog'y. — The  causes  of  gastrosuccorrhea  are  the  same 
as  those  which  excite  hyperchlorhydria. 

Symptoms. — In  the  continuous  form  the  symptoms 
appear  regularly,  but  with  varying  intensity,  and  consist  in 
more  or  less  severe  pain,  both  at  the  acme  of  digestion  and 
in  the  night ;  vomiting  of  large  quantities  of  yellowish,  acid 
fluid,  even  when  the  ingesta  are  no  longer  in  the  stomach ; 
marked  thirst ;  acid  eructations  ;  and  headache,  sometimes 
of  a  migrainous  type.  The  ingestion  of  a  small  quantity  of 
albuminous  food  usually  relieves  the  pain.  Albumin  diges- 
tion is  good,  but  starch  digestion  is  retarded.  The  diag- 
nosis is  rendered  certain  by  the  finding  of  from  50  c.c.  to 
500  c.c.  or  more  of  gastric  juice,  without  a7iy  admixture  of 
food,  in  the  stomach  before  breakfast,  particularly  if  lavage 
has  been  practised  the  night  before. 

Complications. — Gastrectasis  may  result  from  imperfect 
4 


50  DISEASES   OF   THE  ■  DIGESTIVE   SYSTEM. 

digestion  of  starches  or  from  spasm  of  the  pylorus  excited 
by  excessive  acidity.  Ulcer  may  coexist.  In  rare  instances 
tetany  develops. 

Diagnosis. — In  hyperchlorhydria  the  resting  stomach  is 
empty  and  pain  does  not  occur  at  night.  Care  must  be 
taken  to  exclude  locornotor  ataxia,  of  which  intermittent 
gastrosuccorrhea  may  be  an  early  symptom. 

Prognosis.  —  Guardedly  favorable  in  uncompHcated 
cases.     Relapses  are   common. 

Treatment. — This  is  much  the  same  as  that  for  hyper- 
chlorhydria. The  painful  attacks  may  be  relieved  by  the 
administration  of  alkalis,  or,  better,  by  thorough  lavage. 
Belladonna  appears  to  possess  some  power  to  reduce  gastric 
secretion. 

GASTRALGIA* 

(Gastrodynia;  Neuralgia  of  the  Stomach.) 

Definition. — Violent  paroxysmal  gastric  pain,  occurring 
independently  of  any  organic  disease  of  the  stomach  and  of 
any  disturbances  of  secretion  or  motility. 

!^tiology. — It  is  more  common  in  women  than  in  men. 
Overwork,  worry,  sexual  excesses,  abuse  of  tobacco,  reflex 
irritation,  and  anemia  predispose  to  it.  It  may  be  a  symp- 
tom of  neurasthenia. 

Symptoms. — The  characteristic  features  are  paroxysms 
of  intense  pain,  occurring  suddenly  at  irregular  intervals, 
radiating  to  the  chest  and  back,  bearing  no  definite  relation 
to  eating,  and  lasting  from  a  few  minutes  to  several  hours. 
Vomiting  is  rare.  Pressure  over  the  stomach  may  relieve 
the  pain,  and  so  may  the  taking  of  food. 

Diagnosis. — Idiopathic  gastralgia  must  be  separated 
from  the  paroxysmal  pain  that  occurs  in  gastric  ulcer,  gas- 
tric cancer,  hyperchlorhydria,  locomotor  ataxia,  angina  pec- 
toris, and  in  renal  and  biliary  colic. 

Gastric  Ulcer. — Pain  is  excited  by  food  and  digestion,  dis- 
appears upon  evacuation  of  the  stomach,  is  associated  with 
hyperacidity,  and  often  with  vomiting,  hematemesis,  and 
local  tenderness. 


GASTRALGIA.  5 1 

Gastric  Cancer. — The  pain  is  usually  more  or  less  con- 
tinuous, and  is  aggravated  by  digestion.  There  may  be 
persistent  vomiting,  hematemesis,  cachexia,  inacidity  with 
lactic-acid  fermentation,  and  a  palpable  tumor. 

HypercMorhydria. — The  pain  is  digestive,  and  is  relieved 
by  alkalis  and  by  albuminous  food.  Examination  of  the 
stomach-contents  reveals  excess  of  HCl. 

Crises  of  Tabes. — Unsteadiness  of  gait  and  of  station, 
Argyll-Robertson  pupil,  shooting  pains  in  the  Hmbs,  abnor- 
malities of  sensation,  and  abolition  of  deep  reflexes  will  indi- 
cate locomotor  ataxia. 

Angina  Pectoris. — The  pain  radiates  from  the  heart  to  the 
neck  and  arm,  is  frequently  excited  by  exertion  or  indiscre- 
tions in  diet,  is  generally  of  short  duration,  is  often  attended 
with  immobility  of  the  body  and  a  feeling  of  imminent  dis- 
solution, and  is  usually  associated  with  the  signs  of  arterio- 
sclerosis. 

Renal  Colic. — The  pain  radiates  from  the  kidney  into  the 
ureter  of  the  affected  side,  and  concretions  or  blood  may  be 
found  in  the  urine. 

Biliary  Colic. — The  pain  is  usually  in  the  right  hypochon- 
driac region,  and  is  often  accompanied  by  chill,  fever,  and 
jaundice.  The  liver  and  gall-bladder  may  be  enlarged  and 
tender. 

Prognosis. — Favorable  in  uncomplicated  cases. 

Treatment. — The  Attack. — Hot  applications  are  useful. 
Galvanization  (the  anode  over  the  stomach  and  the  cathode 
near  the  spinal  column)  often  affords  prompt  relief  The 
most  generally  efficacious  remedies  are  antipyrin  (8  grains), 
brandy  (i  to  2  fluidrams),  aromatic  spirit  of  ammonia 
(|-  fluidram),  chloroform  (2  to  5  minims),  and  diluted  hydro- 
cyanic acid  (2  minims).  These  remedies  are  most  efficacious 
when  given  in  hot  water.  Such  a  combination  as  the  fol- 
lowing is  frequently  successful : 

R.     Chloroformi      f^iss 

Spiritus  ammonise  aromatici 

Spiritus  vini  gallici 

Tincturae  cardamomi  compositse     .      aa  f:^v. — M. 
SiG. — A  teaspoonful  in  hot  water  every  fifteen  or  thirty  minutes. 


52  DISEASES   OF  THE   DIGESTIVE   SYSTEM. 

In  very  severe  cases  it  will  be  necessary  to  resort  to 
morphin. 

The  Interval. — The  cause  must  be  ascertained,  and,  if  pos- 
sible, removed.  The  habits  of  the  patient  must  be  corrected. 
Methods  of  treatment  intended  to  improve  the  general 
nutrition  are  of  the  greatest  value.  When  there  is  anemia, 
iron  will  be  found  very  useful.  Among  special  remedies 
arsenic,  valerianates,  sumbul,  quinin,  and  cannabis  indica  are 
available.  The  following  combination  often  proves  effica- 
cious : 

R  •     Arseni  trioxidi .    .  gr.  i 

Quininae  valeratis :  gr.  xxx 

Ferri  pyrophosphatis 

Extracti  sumbul aa  gr.  xx, — M. 

riant  in  pilulae  No.  xx. 

SiG. — One  pill  after  each  meal. 

In  some  cases  a  complete  change  of  scene  or  enforced 
rest  in  bed  for  a  given  period  is  the  only  means  of  effecting 
a  cure. 

PEPTIC  ULCER* 

(Round  Ulcer  of  the  Stomach;    Perforating  Ulcer.) 

Definition. — A  circumscribed  loss  of  tissue  in  the 
stomach,  usually  involving  both  the  mucous  membrane 
and  the  deeper  structures,  and  characterized  clinically  by 
paroxysmal  pain,  localized  tenderness,  vomiting,  hemat- 
emesis,  and  hyperacidity  of  the  gastric  juice. 

Similar  lesions  occur  in  the  duodenum  and  in  the  lower 
end  of  the  esophagus. 

i^tiolog'y. — It  is  more  common  in  women  than  in  men. 
The  majority  of  cases  occur  between  the  ages  of  twenty 
and  forty.  Chlorosis  and  anemia  are  important  predisposing 
factors. 

Duodenal  ulcer  not  infrequently  follows  large  superficial 
burns. 

Pathogenesis. — It  is  generally  admitted  that  these  ulcers 
are  due  to  the  digestive  action  of  highly  acid  gastric  juice 
upon  a  part  of  the  stomach  that  has  been  devitalized  in 
consequence  of  embolism   or  thrombosis  with    infarction, 


PEPTIC   ULCER.  53 

Spasm  of  the  blood-vessels,  disease  of  the  vessel-walls,  or 
external  injury. 

Pathology. — As  a  rule,  the  ulcers  are  single,  but  they 
may  be  multiple.  The  most  frequent  seat  is  the  posterior 
wall,  in  the  lesser  curvature,  near  the  pylorus.  They  have 
a  punched-out  appearance,  are  round  or  oval  in  outline,  and, 
if  recent,  are  funnel-shaped,  with  the  apex  toward  the 
serous  coat.  The  edges  are  usually  smooth,  rarely  ragged. 
They  vary  in  diameter  from  a  few  millimeters  to  several 
centimeters,  and  may  extend  to  the  muscularis  or  even  to 
the  serosa. 

Symptoms. — Symptoms  of  indigestion  are  generally 
present.     The  characteristic  symptoms  are  : 

1.  Pain. — This  is  usually  paroxysmal,  severe,  and  local- 
ized. It  may  radiate  to  the  back  or  sides.  It  is  closely 
associated  with  eating,  reaches  its  acme  at  the  height  of 
digestion,  is  aggravated  by  coarse,  very  hot,  acid  and  spicy 
foods,  is  often  affected  by  certain  positions  of  the  body,  is 
arrested  by  vomiting,  and  subsides  spontaneously  upon  the 
natural  evacuation  of  the  stomach. 

2.  Localized  Tenderness. — Two  small  areas  of  tenderness 
can  often  be  elicited,  one  in  front  below  the  ensiform  car- 
tilage, and  one  behind,  in  the  dorsal  region,  a  little  to  the 
left  of  the  spine. 

3.  Vomiting. — This  frequently  occurs  in  from  one-half  to 
two  hours  after  eating.  The  vomit  usually  consists  of  undi- 
gested food  and  acid  fluid. 

4.  Hematemesis. — This  occurs  in  at  least  one-half  of  all 
cases.  It  proves  fatal  in  about  3  per  cent,  of  the  cases  of 
ulcer.  The  blood  is  generally  fluid  and  unaltered,  but  if 
retained  in  the  stomach  for  some  time,  it  may  have  a  coffee- 
ground  appearance.  Occasionally  the  blood  is  discharged 
entirely  by  the  bowel. 

5.  Hyperacidity. — An  increase  of  HCl  is  almost  invariably 
noted  after  a  test-meal. 

In  some  cases  only  the  symptoms  of  dyspepsia  are  pres- 
ent, while  in  others  all  symptoms  are  absent,  the  disease 
passing  unrecognized  until  sudden  perforation  or  profuse 
hemorrhage  occurs. 


54  DISEASES   OF  THE  DIGESTIVE  SYSTEM. 

Sequels. — (i)  Perforation.  This  occurs  most  frequently 
in  ulcers  on  the  anterior  wall  and  in  about  6  per  cent, 
of  all  cases.  (2)  General  or  circumscribed  peritonitis.  Gen- 
eral peritonitis  is  usually  the  result  of  perforation ;  cir- 
cumscribed productive  peritonitis  is  a  conservative  process 
and  results  from  the  direct  extension  of  the  inflammatory 
process  through  the  stomach-walls.  (3)  Subphrenic  abscess. 
This  is  usually  the  result  of  perforation  after  the  formation 
of  adhesions.  (4)  Stenosis  of  the  pylorus,  stenosis  of  the 
cardia,  or  hour-glass  constriction  of  the  stomach  may  result 
from  the  contraction  of  cicatrices.  (5)  Cancer  not  infre- 
quently develops  on  the  basis  of  an  old  ulcer. 

Diagnosis. — Hyperchlorhydria. — In  this  condition  the 
pain  does  not  occur  so  regularly  nor  so  soon  after  eating ; 
it  is  not  modified  by  position,  but  is  often  completely  re- 
lieved by  eating  albuminous  food.  Hematemesis  is  absent 
and  there  are  no  tender  spots. 

Gastralgia. — In  this  affection  the  pain  occurs  at  irregular 
intervals,  is  not  dependent  upon  eating  (often  occurring 
when  the  stomach  is  empty),  is  relieved  by  pressure,  and  is 
not  associated  with  tender  spots,  hematemesis,  or  hyper- 
acidity. 

Cancer  of  the  Stomach. — The  history,  rapid  course,  ad- 
vanced cachexia,  palpable  tumor,  vomiting  of  large  quan- 
tities of  undigested  food  at  long  and  irregular  intervals, 
coffee-ground  vomit,  abundance  of  lactic  acid  with  Boas- 
Oppler  bacilli,  and  the  absence  of  free  hydrochloric  acid 
will  point  to  cancer. 

Duodenal  Ulcer. — In  this  disease  the  pain  is  further  to  the 
right  and  occurs  later  after  the  meals,  the  blood  is  usually 
evacuated  through  the  bowel,  and  there  is  no  vomiting. 

Cholelithiasis. — In  this  condition  the  pains  appear  more 
suddenly,  occur  at  more  irregular  intervals,  and  often  inde- 
pendently of  eating,  usually  radiate  toward  the  right  shoul- 
der, and  are  often  associated  with  swelling  and  tenderness 
of  the  liver,  enlargement  of  the  gall-bladder,  and  slight 
jaundice. 

Prog"nosis. — Guardedly  favorable  in  recent  cases.  The 
mortality  in  all  cases  is  from  8  to  10  per  cent.     Some  ulcers 


PEPTIC   ULCER.  55 

run  a  rapid  course  and  end  fatally  in  hemorrhage  or  perfora- 
tion ;  others,  even  without  treatment,  persist  for  many  years. 
Relapses  are  not  uncommon. 

Treatment. — Rest  and  appropriate  diet  are  the  most 
important  factors  in  the  treatment.  The  rest  should  be 
kept  up  for  from  six  to  twelve  weeks,  and  for  the  first 
two  or  three  weeks  of  this  period  the  patient  should  be 
confined  to  bed.  If  hemorrhage  has  recently  occurred  or 
if  vomiting  be  urgent,  it  is  advisable  to  withhold  all  food 
from  the  stomach  for  a  few  days  and  to  nourish  the  patient 
by  means  of  nutritive  enemas. 

After  the  pain  and  vomiting  have  sensibly  abated,  feeding 
by  the  mouth  should  be  resumed.  The  diet  should  con- 
sist of  milk,  buttermilk,  beef-juice,  animal  broths,  egg- 
white,  and  thin  pap.  As  soon  as  the  gastric  symptoms 
have  completely  disappeared,  which  will  rarely  be  before 
the  lapse  of  three  or  four  weeks,  the  patient  may  be  allowed 
such  articles  as  soft-boiled  eggs,  scraped  beef,  boiled  sweet- 
breads, the  tender  part  of  oysters,  white  meat  of  chicken, 
well-made  gruel,  and  custard  pudding. 

The  most  useful  drugs  are  alkalis,  silver  nitrate,  and  bis- 
muth subnitrate.  The  alkalis  are  useful  in  overcoming  the 
superacidity  of  the  gastric  juice.  Sodium  bicarbonate  is 
one  of  the  best;  it  may  be  combined  with  magnesia  or 
chalk,  according  as  there  is  constipation  or  diarrhea.  Arti- 
ficial Carlsbad  salt  (see  p.  44)  is  an  excellent  alkaline  lax- 
ative ;  of  this,  a  teaspoonful  or  more  may  be  given  in  a  half 
pint  of  hot  water  in  the  early  morning.  Silver  nitrate  and 
bismuth  subnitrate  are  valuable  remedies  and  may  be  used 
alternately,  each  for  a  period  of  a  week  or  ten  days.  They 
may  be  prescribed  as  follows  : 

R.    Argenti  nitratis 

Extract!  belladonnse aa  gr.  vj. — M, 

Fiant  pilulse  No.  xx. 

SiG. — One  pill  half  an  hour  before  meals. 

R.    Bismuthi  subnitratis "T^v] 

Acidi  hydrocyanici  diluti ff^xxiv 

Aquae f^vj. — M. 

SiG. — A  tablespoonful  three  or  four  times,  half  an  hour  before 
meals. 


56  DISEASES   OF  THE  DIGESTIVE   SYSTEM. 

Pain  and  vomiting  usually  yield  to  complete  rest,  rectal 
feeding,  and  the  administration  of  silver  nitrate  or  bismuth 
subnitrate.  In  some  cases  it  may  be  necessary  to  use  mor- 
phin  hypodermically.  Externally,  stupes  or  sinapisms  are 
sometimes  useful.  The  treatment  of  hematemesis  is  con- 
sidered on  page  63. 

Surgical  Treatment. — In  all  cases  of  perforation  an  opera- 
tion should  be  done  at  the  earliest  possible  moment.  When 
life  is  threatened  by  repeated  hemorrhage,  operation  in  the 
interval  between  the  attacks  offers  the  best  method  of  reHef 
Again,  an  operation  (gastro-enterostomy,  pyloroplasty,  or 
partial  gastrectomy)  should  be  considered  if  the  disease 
does  not  yield  to  medical  treatment  and  the  life  of  the 
patient  is  endangered  by  malnutrition. 

CANCER  OF  THE  STOMACH* 

etiology. — Sex. — Cancer  of  the  stomach  is  somewhat 
more  common  in  men  than  in  women. 

Age. — The  majority  of  cases  occur  between  the  ages  of 
forty  and  sixty.     It  is  rare  before  thirty. 

Heredity. — About  8  per  cent,  of  the  cases  appear  to  be 
hereditary. 

Prolonged  Irritation. — Cancer  sometimes  develops  on  the 
basis  of  an  old  ulcer. 

Pathology. — Cancer  of  the  stomach  is  almost  always 
primary.  The  pylorus  is  the  part  most  frequently  attacked. 
After  the  pylorus  the  points  of  predilection  are  the  lesser 
curvature  and  cardia.  The  following  varieties  are  encoun- 
tered :  Scirrhus  or  hard  cancer,  medullary  or  soft  cancer, 
adenocarcinoma  (cylindric-celled  epithelioma),  colloid  can- 
cer, and  squamous-celled  epithelioma.  Ulceration  is  rare 
in  scirrhus,  but  common  in  medullary  cancer  and  adeno- 
carcinoma. Colloid  cancer  appears  most  commonly  as  a 
diffuse  infiltration  of  the  stomach-wall.  Squamous-celled 
cancer  is  rare,  and  occurs  only  at  the  cardia. 

Owing  to  stenosis  of  the  pylorus  the  stomach  is  usually 
dilated.  Stagnation  of  the  stomach-contents  and  the  ab- 
sence of  hydrochloric-acid  secretion  favor  the  development 
of  lactic-acid  fermentation. 


CANCER    OF  THE   STOMACH.  5/ 

Symptoms. — Symptoms  of  dyspepsia  are  generally 
present.     The  characteristic  phenomena  are  : 

1.  Pain. — This  is  rarely  intense ;  though  aggravated  by 
eating,  it  is  often  more  or  less  continuous.  It  may  radiate 
to  the  back. 

2.  Vomiting. — This  is  very  common.  When  the  pylorus 
is  obstructed,  the  vomiting  is  persistent  and  occurs  long 
after  eating,  sometimes  at  intervals  of  several  days.  The 
vomit  is  frequently  large  in  amount,  and  is  composed  chiefly 
of  undigested  food  and  turbid  fluid.  It  very  rarely  con- 
tains sarcinae,  but  long,  thread-like  bacilli  (Boas-Oppler 
bacilli)  are  almost  constantly  present  and  possess  some 
diagnostic  significance. 

3.  Hematemesis. — As  the  bleeding  is  slight  and  the  blood 
remains  for  some  time  in  the  stomach,  the  vomit  in  many 
cases  acquires  a  coffee-ground  appearance. 

4.  Cachexia. — The  anemia,  weakness,  and  emaciation  are 
often  disproportionate  to  the  loss  of  nourishment. 

5.  Palpable  Tnnior. — A  movable,  tender  mass  can  be  de- 
tected sooner  or  later  in  a  large  proportion  of  all  cases. 

6.  Absence  of  HCl  zvitli  Lactic-acid  Ferme7itation. — The 
absence  of  free  HCl  and  the  presence  of  large  quantities  of 
lactic  acid,  while  not  pecuhar  to  cancer,  are  strongly  indica- 
tive of  the  disease. 

In  addition  to  these  features  the  symptoms  and  signs  of 
gastrectasis  are  frequently  present. 

Complications  and  Sequels. — Metastases  in  neigh- 
boring structures — liver,  lymph-glands,  pancreas,  and  peri- 
toneum— are  of  common  occurrence.  Ascites  and  edema 
are  occasionally  encountered.  Perforation,  subphrenic  ab- 
scess, tetany,  venous  thrombosis,  multiple  neuritis,  and  coma 
(from  oxybutyric-acid  intoxication)  are  rare  complications. 

Diagnosis. — The  differential  points  between  cancer  and 
ulcer  and  cancer  and  chronic  gastritis  have  already  been 
considered. 

Prognosis. — The  disease  is  almost  invariably  fatal.  The 
average  duration  of  life  is  from  one  to  two  years.  Marked 
temporary  improvement  frequently  occurs  under  treatment 
and  may  prove  very  misleading. 


58  DISEASES    OE   THE  DIGESTIVE   SYSTEM. 

Treatment. — In  the  early  stages  of  the  disease,  when 
the  pylorus  is  still  patulous,  a  mixed  diet  of  readily  digested 
food  is  often  well  borne.  Later,  when  there  is  retention, 
food  should  be  selected  that  will  make  small  demands  on 
the  stomach  and  that  will  leave  little  residue.  Bitters — 
calumba,  gentian,  condurango — are  sometimes  employed 
with  advantage.  In  many  cases,  but  by  no  means  invaria- 
bly, hydrochloric  acid  and  pepsin  are  useful.  Lavage 
affords  the  best  means  of  relieving  the  distressing  symptoms 
resulting  from  retention.  Vomiting  not  dependent  upon 
retention  may  be  treated  with  such  remedies  as  carbonated 
water,  hydrocyanic  acid,  creasote,  cerium  oxalate,  and  bis- 
muth subnitrate.  In  obstinate  cases  rectal  feeding  may  be 
required  for  a  time.  Acid  eructations  and  flatulency  are 
sometimes  relieved  by  antacids  and  internal  antiseptics,  but 
generally  lavage  is  much  more  effective.  Pain  will  require 
opium,  sedatives  like  hydrocyanic  acid  or  chloroform,  and 
hot  applications. 

Early  operative  interference  may  prolong  life  for  several 
months  or  several  years. 

DILATATION  OF  THE  STOMACH. 

(Gastrectasis.) 

Ktiology. — Gastrectasis  may  result  from — (i)  Atony  of 
the  stomach-walls  (see  p.  45);  (2)  from  stenosis  of  the 
pylorus. 

Stenosis  of  the  pylorus  may  be  caused  by — {a)  Congenital 
stricture ;  (B)  carcinoma  of  the  pylorus ;  (c)  cicatrix  from 
ulcer;  {d^  hypertrophy  of  the  pylorus  from  gastric  catarrh 
or  frequent  spasm  excited  by  hypersecretion  ;  {e)  pressure 
from  without,  as  by  tumors,  adhesions,  floating  kidney,  etc. 

Pathology. — All  degrees  of  dilatation  are  encountered. 
The  most  severe  forms  are  usually  the  result  of  pyloric 
stenosis.  In  atonic  dilatation  the  stomach-walls  are  thin 
and  atrophic ;  in  dilatation  from  obstruction  there  may  be 
marked  muscular  hypertrophy  at  the  pyloric  end. 

Symptoms. — These  vary  with  the  cause  and  the  degree 
of  dilatation.     In  well-marked  cases  the  chief  symptoms  are 


DILATATION  OF   THE   STOMACH.  59 

a  feeling  of  fulness  and  discomfort  after  meals,  frequent 
belching  and  acid  eructations,  increased  thirst,  constipation, 
deficient  urination,  and  more  or  less  emaciation.  Owing  to 
reflex  irritation  or  autointoxication  nervous  symptoms  often 
develop. 

Vomiting  is  a   characteristic   symptom,   especially  when 
there  is  stenosis  of  the  pylorus.     It  occurs  long  after  meals, 
sometimes  at  intervals  of  several  days.     The  vomit  is  often 
excessive    in    amount,    is    sour    and    fer- 
mented, and  on  standing  separates  into  a 
sediment  of  undigested  food  and  a  super-      ^^      ^        *» 
natant  liquid,  which  is  turbid  and  frothy.  8B**<5 

Not  infrequently  the  vomit  contains  rem- 
nants of  food  that  was  eaten  several  days  ^    ^ 
before.     Microscopic  examination  may  re-  ** 
veal,  in  atonic  dilatation,  numerous  yeast- 
cells  and  sarcinae,  and  in  cancerous  dila- 
tation, the  thread-like  bacilli  of  Oppler. 

Physical  Signs. — Inspection. — The  abdo- 

,  1    1  •  ,         T  Fig.  I. — a,  Sarcmae 

men  may  be  unduly  promment.     In  some     ventricuii.  b,  Toruise 
cases  the  outlines  of  the  enlarged  stomach     cerevisiae. 
are  distinctly  visible.     Peristaltic  waves  ex- 
tending from  left  to  right  are  frequently  seen,  especially  in 
stenotic  dilatation. 

Palpation. — When  the  stomach-walls  are  sufficiently  tense, 
the  boundaries  of  the  organ  may  be  determined  by  palpa- 
tion. In  many  cases  of  obstructive  dilatation  a  tumor  can 
be  felt  at  the  pylorus. 

Percussion.— V\lhQn  the  stomach  contains  fluid,  an  area 
of  dulness  is  found  at  the  level  of  the  umbilicus,  or  below  it 
when  the  patient  is  erect,  but  not  when  he  is  lying  down. 
This  area  of  dulness  also  disappears  upon  the  complete 
evacuation  of  the  stomach. 

After  artificial  inflation  of  the  stomach  with  air  or  car- 
bonic-acid gas  percussion  reveals  an  increased  area  of  gastric 
tympany. 

Auscultation. — The  detection  of  splashing  sounds  over  the 
stomach  in  the  morning  before  breakfast  or  seven  hours 
after  a  Riegel  test-meal  points  to  dilatation. 

Mensuration. — Normally  a  rigid  sound  can  be  inserted  a 


6o  DISEASES   OF  THE   DIGESTIVE   SYSTEM. 

distance  of  24  inches  (60  cm.)  from  the  incisor  teeth  ;  in 
dilatation  it  may  be  inserted  as  much  as  28  inches  (70  cm.). 
As  the  depth  to  which  the  sound  can  be  passed  is  frequently 
increased  also  in  gastroptosis,  this  sign  is  unreliable. 

X-7'ays. — Skiagraphs  taken  after  the  ingestion  of  large 
quantities  of  bismuth  subnitrate  suspended  in  mucilage  of 
acacia  have  proved  of  value  in  the  diagnosis  of  gastrectasis. 

Examination  of  the  Stomach-contents. — The  detection  of 
remnants  of  food  in  the  stomach  in  the  morning  after  a 
simple  supper  renders  the  diagnosis  of  severe  motor  insuf- 
ficiency certain,  and  that  of  dilatation  highly  probable. 

Complications. — Gastroptosis  is  a  common  complica- 
tion ;  it  may  be  secondary  to  the  dilatation  or  the  cause  of 
it.     Tetany  is  a  rare,  but  serious,  complication. 

Diagnosis. — Gastroptosis. — In  uncomplicated  gastropto- 
sis the  position  of  the  stomach  is  lower  down  than  normal 
and  more  or  less  vertical,  but  the  area  of  gastric  tympany  is 
not  increased  nor  are  there  present  any  signs  of  motor 
insufficiency. 

Type  of  Dilatation. — A  rapid  onset,  persistent  vomiting, 
pain,  a  high  degree  of  motor  insufficiency  with  marked 
dilatation,  a  tardy  inflow  and  a  rapid  outflow  of  water  dur- 
ing lavage,  active  gastric  peristalsis,  a  palpable  tumor  at  the 
pylorus,  and  rapid  emaciation  suggest  pyloric  obstruction. 

Prognosis. — This  depends  upon  the  cause,  degree,  and 
duration  of  the  dilatation.  In  pyloric  obstruction  the  prog- 
nosis is  very  grave,  although  operation  may  lead  to  cure, 
especially  in  benign  forms.  Even  in  atonic  dilatation  the 
prognosis  must  be  guarded  if  the  process  is  advanced  and 
there  is  pronounced  motor  insufficiency. 

Treatment. — The  food  should  be  nutritious,  small  in 
bulk,  and  readily  digestible,  and,  in  advanced  cases,  should 
be  given  in  small  amounts  at  frequent  intervals.  Liquids 
should  never  be  given  in  large  quantities.  In  severe  grades 
of  dilatation,  to  prevent  the  tissues  from  losing  water,  it  is 
advisable  to  introduce  fluids  in  the  form  of  water  and  meat- 
broth  by  the  bowel.  To  prevent  retention,  to  control  fer- 
mentation, and  to  cleanse  the  stomach,  no  measure  is  so 
useful  as  methodic  lavage.  When  there  is  considerable 
retention,  the  lavage  should  be  performed  daily,  preferably 


GASTROPTOSIS  AND   ENTEROPTOSIS ^  6l 

in  the  early  morning.  A  carefully  adjusted  abdominal 
bandage  nearly  always  affords  comfort  and  gives  mechanical 
support  to  the  stomach.  In  cases  due  to  atony  exercise  in 
the  open  air,  hydrotherapy,  and,  unless  there  be  marked 
gaseous  fermentation,  abdominal  massage  are  valuable  aids. 
Faradization  of  the  stomach  may  also  be  used  to  promote 
muscular  contraction.  In  dilatation  from  muscular  relaxa- 
tion nux  vomica  is  very  useful.  Such  remedies  as  creasote, 
salol,  and  bismuth-beta-naphthol  are  sometimes  of  service 
in  checking  fermentation,  but  the  relief  they  afford  is  not  to 
be  compared  to  that  obtained  by  systematic  lavage.  Con- 
stipation is  best  treated  by  simple  enemas  or  by  glycerin 
suppositories. 

Surgical  Treatment. — In  the  large  majority  of  cases  of 
non-obstructive  dilatation  medical  treatment  suffices.  Occa- 
sionally, however,  surgical  intervention  is  demanded  on 
account  of  persistent  suffering  and  progressive  emaciation. 
The  operation  indicated  in  these  cases  is  gastroplication. 
In  cases  of  pyloric  obstruction  of  a  benign  character  an 
operation  is  indicated  when  it  is  impossible  to  maintain 
nutrition  by  proper  medical  treatment.  As  Loreta's  digital 
divulsion  of  the  pylorus  has  been  largely  abandoned,  owing 
to  its  high  mortality  (31.1  per  cent),  there  may  be  said  to 
be  but  two  operations  available — pyloroplasty  and  gastro- 
enterostomy. The  treatment  of  pyloric  cancer  is  considered 
on  page  58. 

GASTROPTOSIS  AND  ENTEROPTOSIS. 

(Glenard's  Disease.) 

Definition.— Prolapse  of  the  stomach  and  transverse 
colon  caused  by  congenital  or  acquired  weakness  of  the 
abdominal  muscles  and  ligaments. 

Btiology. — The  condition  is  much  more  common  in 
women  than  in  men.  Tight  lacing,  repeated  pregnancies, 
abnormal  formation  of  the  thorax,  enlargement  of  other 
abdominal  organs,  gastrectasis,  and  constitutional  weakness 
are  important  predisposing  factors. 

Symptoms. — The  chief  objective  feature  is  a  more  or 
less  pronounced  downward  displacement  of  the  pylorus,  in 


62  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

consequence  of  which  the  stomach  assumes  a  vertical  or 
subvertical  position.  Dislocation  of  the  whole  stomach 
downward  is  rare„  Dilatation  of  the  pyloric  extremity  is  a 
common  sequel.  The  position  and  size  of  the  viscus  can 
be  determined  accurately  only  after  artificial  inflation.  The 
transverse  colon  shares  in  the  downward  displacement  of 
the  stomach  and  occupies  a  position  immediately  below  the 
greater  curvature.  Ptosis  of  other  abdominal  organs,  espe- 
cially of  the  right  kidney  and  liver,  is  also  present  in  many 
cases.  Separation  of  the  recti  muscles  is  often  seen.  A 
floating  tenth  rib  is   less  frequent. 

The  subjective  symptoms  are  those  of  motor  insufficiency 
or  atony  of  the  stomach, — fulness  and  distress  after  meals, 
splashing,  gaseous  eructation,  pain  in  the  back,  and  consti- 
pation,— combined,  in  many  cases,  with  more  or  less  marked 
neurasthenia. 

Treatment. — The  diet  should  be  adapted  to  the  diges- 
tive and  motor  powers  of  the  stomach.  Mechanical  support 
of  the  pylorus  by  means  of  a  snugly  fitting  abdominal 
bandage  affords  relief  in  mild  cases.  In  severe  cases,  espe- 
cially when  the  nervous  phenomena  are  pronounced,  a 
modified  rest-cure  may  prove  effective.  Lavage  is  not 
indicated  unless  there  is  general  dilatation  with  retention  or 
excessive  secretion  of  mucus.  In  very  obstinate  cases  sur- 
gical intervention  should  be  considered. 

HEMATEMESIS* 

(Gastrorrhagia.) 

^tiologfy. — Hemorrhage  from  the  stomach  may  result 
from — (i)  Traumatism;  (2)  gastric  ulcer;  (3)  gastric  can- 
cer ;  (4)  venous  engorgement  of  the  stomach  following  cir- 
rhosis of  the  liver,  primary  splenomegaly,  or  chronic  heart 
disease  ;  (5)  acute  gastritis  ;  (6)  blood  dyscrasia,  as  in  scurvy, 
purpura,  severe  infections,  and  grave  anemias;  (7)  rupture 
of  an  aneurysm ;  (8)  swallowing  of  blood  from  the  nose, 
mouth,  or  throat;  (9)  vicarious  menstruation;  (10)  hysteria. 

Symptoms. — The  quantity  of  blood  that  is  vomited 
varies   considerably  :   rarely  a  quart   or  more  is   lost.     In 


HABITUAL    CONSTIPATION.  63 

many  cases  a  portion  of  the  blood  escapes  through  the 
bowel.  The  blood  is  usually  dark,  is  often  mixed  with 
food,  has  an  acid  reaction,  and  may  be  fluid  or  clotted.  If 
the  hemorrhage  is  severe,  the  symptoms  of  acute  anemia 
develop — pallor,  weakness,  vertigo,  tinnitus  aurium,  dim- 
ness of  sight,  syncope,  and  convulsions. 

Diagnosis. — Hemoptysis.— T\\^  blood  is  coughed  up  ;  it 
is  usually  bright  red,  frothy,  and  alkaline  in  reaction ;  sub- 
sequent expectorations  are  tinged  with  blood,  and  the  asso- 
ciated symptoms  and  signs  point  to  pulmonary  or  cardiac 
disease. 

Prognosis. — Hematemesis  is  rarely  so  severe  as  to  cause 
death.  The  most  dangerous  hemorrhages  are  those  that 
occur  in  cirrhosis  of  the  liver,  splenomegaly,  and  aneurysm. 

Treatment. — In  the  treatment  of  hematemesis  absolute 
rest  is  essential.  No  food  of  any  kind  should  be  given  by 
the  mouth.  An  ice-bag  should  be  applied  over  the  stomach, 
and  morphin  should  be  given  hypodermically.  The  appli- 
cation of  firm  bandages  to  the  four  extremities  may  act 
favorably.  Ergot  and  such  drugs  as  tannic  acid,  iron  sul- 
phate, and  lead  acetate  are  of  very  doubtful  utility.  A  solu- 
tion of  adrenalin  chlorid  (i  :  1000)  is  worthy  of  trial. 
Twenty  minims  may  be  given  in  half  an  ounce  of  water 
every  hour.  When  the  bleeding  is  prolonged,  three  or  four 
ounces  of  a  solution  of  gelatin  (10  to  15  per  cent.)  may  be 
given  several  times  a  day. 

Collapse  following  hemorrhage  will  call  for  diffusible 
stimulants,  the  external  application  of  heat,  and  the  subcu- 
taneous or  intravenous  injection  of  warm  saline  solution. 

HABITUAL  CONSTIPATION. 

Definition. — Infrequent  or  difficult  evacuation  of  the 
feces. 

!^tiolog"y. — The  chief  causes  are  :  (i)  Many  general  dis- 
eases that  lessen  the  intestinal  secretions  or  inhibit  peri- 
stalsis, such  as  the  acute  fevers,  anemia,  diabetes,  neurasthe- 
nia, hysteria,  and  organic  affections  of  the  brain  and  spinal 
cord.     (2)   Many  diseases  of  the  digestive  tract — chronic 


64  DISEASES   OF  THE  DIGESTIVE  SYSTEM. 

gastritis,  gastrectasis,  gastric  cancer,  obstructive  jaundice, 
and  chronic  intestinal  catarrh.  (3)  Sedentary  habits.  (4) 
Improper  food.  (5)  Atony  of  the  bowel  and  weakness  of 
the  abdominal  muscles.  (6)  Muscular  spasm  excited  by 
irritable  prostate,  uterine  disease,  ulceration  of  the  rectum, 
or  stricture. 

Symptoms. — Some  persons  continue  to  enjoy  excellent 
health  even  though  their  bowels  are  evacuated  at  very  in- 
frequent intervals.  Generally,  however,  retention  of  fecal 
matter  in  the  intestines  longer  than  is  customary  with  the 
individual  gives  rise  to  unpleasant  symptoms,  common 
among  which  are  headache,  dizziness,  mental  sluggishness, 
lassitude,  fetor  of  the  breath,  a  coated  tongue,  and  anorexia. 

Sequels. — Severe  persistent  constipation  may  lead  to  piles, 
fissure,  ulceration  of  the  colon,  diarrhea  from  irritation,  or 
fecal  impaction. 

Treatment. — The  removal  of  the  cause  is  a  matter  of 
the  first  importance.  Cathartics  should  be  avoided,  if  possi- 
ble. In  some  cases  the  activity  of  the  bowels  is  restored 
by  repeated  daily  attempts  at  defecation  at  some  special 
hour.  Systematic  exercise  and  cold  bathing  are  of  the 
greatest  benefit.  Abdominal  massage,  especially  digital 
kneading  in  the  direction  of  the  colon,  is  often  quite 
effectual. 

Unless  the  state  of  digestion  offers  a  contraindication, 
such  laxative  articles  of  food  as  green  vegetables,  oatmeal, 
cornmeal,  whole-wheat  bread,  oils,  and  cooked  fruits  should 
be  ordered.  Water-drinking  should  be  encouraged.  In 
mild  cases  a  glass  of  cold  water  before  breakfast  may 
suffice. 

General  tonics,  like  iron  and  strychnin,  are  sometimes 
needed.  Mineral  waters,  hke  Friedrichshall,  Hunyadi  Janos, 
or  the  milder  Saratoga  or  Bedford  waters,  are  very  useful, 
but  possess  no  special  advantages  over  the  sahne  laxatives 
(sodium  phosphate  or  Rochelle  salt),  when  the  latter  are 
taken  in  small  amounts  well  diluted.  Enemas  of  soapy 
water  or  of  glycerin  or  suppositories  of  gluten,  soap,  or 
glycerin,  often  prove  highly  satisfactory.  Vegetable  cathar- 
tics are  usually  necessary  in  obstinate  cases.     The  mild  ones 


INTESTINAL    COLIC.  65 

FXiould  always  be  tried  first,  and  even  with  these  considera- 
ble care  should  be  exercised  lest  the  patient  comes  to  rely 
upon  drugs  to  the  exclusion  of  the  hygienic  and  dietetic 
measures  already  indicated.  Of  the  mild  laxatives,  cascara 
sagrada  is  one  of  the  best:  from  10  to  30  minims  of  the 
fluid  extract,  or  a  corresponding  dose  of  an  agreeable  elixir, 
may  be  administered  at  bedtime  and  repeated,  if  necessary, 
in  the  morning. 

In  many  cases  a  combination  of  several  laxatives  (rhu- 
barb, aloes,  podophyllum,  euonymin,  and  colocynth)  acts 
better  than  any  one  singly.  As  adjuvants,  nux  vomica  or 
physostigma  may  be  added  to  overcome  intestinal  atony, 
and  belladonna  or  hyoscyamus  to  prevent  griping.  The 
most  suitable  combination  must  be  determined  in  each  case 
by  experience.  A  pill,  like  one  of  the  following,  will  gen- 
erally prove  satisfactory : 


R.     Aloini 

.    .    .    .  gr.  iv 

Strychninae  sulphatis    .... 

.    .    .    .gr.l 

Extract!  belladonnae     .... 

.    .    ,    .  gr.  uj.- 

-M, 

Fiant  pilulse  No.  xxiv. 

SiG. — One  pill  at  bedtime. 

R.     Pulveris  rhei 

Extracti  rharani  purshiange      .    .    .     aa  gr.  xxiv 

Extracti  euonymi gr.  xij 

Extracti  physostigmatis 

Extracti  belladonnae    ......     aa  gr.  iv. — M, 

Fiant  pilulse  No.  xxiv. 
SiG. — One  pill  at  bedtime. 

INTESTINAL  COLIC 

(Enteralgia;  Tormina.) 

Definition. — Intestinal  pain  of  a  spasmodic  character. 

i^tiology.^ — It  usually  results  from  irritating  ifood,  flatu- 
lence, or  fecal  accumulation.  It  is  sometimes  of  a  rheumatic 
or  gouty  origin.  It  is  a  common  symptom  of  structural 
lesions  of  the  bowel — enteritis,  dysentery,  appendicitis,  in- 
testinal obstruction.  It  is  an  important  symptom  in  chronic 
lead-poisoning.  It  may  be  reflex  from  disease  of  the  ova- 
ries, uterus,  liver,  vertebrae,  etc.  It  may  occur  as  a  crisis  of 
locomotor  ataxia,  • 


66  DISEASES   OE  THE  DIGESTIVE  SYSTEM. 

Symptoms. — Paroxysms  of  severe  pain  of  a  twisting 
character,  centering  around  the  umbilicus,  and  relieved  by 
pressure.  The  abdomen  is  usually  distended.  Severe  at- 
tacks may  .lead  to  collapse,  indicated  by  cold  sweats,  pinched 
features,  feeble  pulse,  and  vomiting.  The  attack  lasts  from 
a  few  minutes  to  several  hours,  and  usually  ends  with  a  dis- 
charge of  flatus. 

Diagnosis. — Lead  Colic. — History,  blue  line  on  the 
gums,  retracted  abdominal  walls,  wrist-drop,  and  lead  in  the 
urine. 

Biliary  Colic. — Pain  radiating  from  the  liver  to  the  back, 
jaundice,  local  tenderness,  and  calculus  in  the  stool. 

Renal  Colic. — Pain  extending  from  the  kidney  along  the 
ureter  to  the  penis  and  testicle,  frequent  micturition,  blood 
or  calculus  in  the  urine. 

Rheumatism  of  the  Abdominal  Muscles. — Pain  is  super- 
ficial, persistent,  and  increased  by  pressure  and  movements 
of  the  body. 

Chronic  Appendicitis. — Localized  tenderness  (McBurney's 
point),  muscular  rigidity,  and  induration. 

Intestinal  Obstruction.  —  Localized  tenderness,  more  or 
less  continuous  pain,  persistent  constipation,  and  incessant 
vomiting,  often  stercoraceous. 

Treatment. — The  indications  are  to  relieve  pain  and  to 
remove  the  cause.  Turpentine  stupes  are  useful.  In  severe 
cases  it  will  be  necessary  to  give  morphin  {^  to  \  grain) 
and  atropin  (yJ-q  grain)  hypodermically.  Carminatives — 
peppermint,  ginger,  oil  of  cloves,  Hoffman's  anodyne — often 
afford  relief. 

Colic  excited  by  irritating  food  or  fecal  accumulation  is 
promptly  relieved  by  saline  or  mercurial  purges. 

DIARRHEA* 

Definition. — A  condition  in  which  the  stools  are  too 
frequent  or  too  liquid.  Like  dyspepsia,  it  is  a  symptom  of 
many  pathologic  conditions. 

etiology. — (i)  It  results  from  inflammation  of  the  intes- 
tines— enteritis,    ileocolitis,    dysentery   (inflammatory    diar- 


INTESTINAL    CATARRH.  6/ 

rhea).  (2)  It  is  a  symptom  of  certain  infectious  diseases, 
such  as  typhoid  fever  and  cholera  (symptomatic  diarrhea). 
(3)  It  may  be  excited  by  cathartic  drugs.  (4)  It  often  oc- 
curs as  a  final  symptom  in  cachectic  states,  as  in  cancer, 
diabetes,  and  chronic  Bright's  disease  (colliquative  diarrhea). 
(5)  It  sometimes  marks  the  crisis  of  acute  infections,  such 
as  typhus  fever  and  pneumonia  (critical  diarrhea).  (6)  It 
may  result  from  nervous  excitement  (nervous  diarrhea). 

INTESTINAL  CATARRH* 

(Diarrhea;    Catarrhal  Enteritis.) 

Ktiology. — Warm  weather,  childhood,  improper  food, 
and  bad  hygienic  surroundings  are  general  predisposing 
factors.  The  disease  is  usually  excited  by  irritating  prod- 
ucts in  the  intestinal  canal  or  by  sudden  changes  in  tem- 
perature. Poisons  produced  in  the  decomposition  of  milk 
and  other  foods  by  bacteria  are  the  most  common  excitants. 
Inorganic  poisons  (arsenic,  antimony,  mercury),  may  also 
induce  acute  diarrhea. 

Pathology. — The  mucosa  is  swollen,  slightly  injected, 
and  covered  with  a  mucous  exudate  composed  of  desqua- 
mated and  degenerated  epithelial  cells  and  leukocytes. 
The  lymph-follicles  are  enlarged  and  occasionally  ulcerated. 

Chronic  enteritis  may  result  from  acute  attacks  or  from 
passive  congestion  in  consequence  of  heart  or  liver  disease. 
The  mucous  membrane  is  pigmented,  and,  in  the  early 
stages,  usually  thickened  from  proliferation  of  the  fixed 
connective-tissue  cells.  In  the  later  stages  atrophy  may 
ensue  from  destruction  of  the  glands  and  shrinking  of  the 
stroma. 

Symptoms. — Acute  Enteritis. — The  chief  symptoms  are 
slight  fever,  with  its  attending  phenomena,  colicky  pains, 
rumbling  noises  (borborygmi),  and  frequent  thin  stools,  of 
a  yellowish  or  greenish  color,  offensive,  and  containing  undi- 
gested food.  The  number  of  stools  varies  from  three  to 
twelve  or  more  a  day.  The  attack  usually  lasts  from  a  few 
days  to  a  week. 

Chronic  enteritis  is   manifested  by  frequent  liquid  stools, 


.■^MK 


6S  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

which  vary  in  color  and  character  according  to  the  seat  of 
the  catarrh,  colicky  pains,  impaired  nutrition,  and  anemia. 
The  presence  in  the  stools  of  much  undigested  food 
(lientery)  indicates  involvement  of  the  small  bowel,  and  the 
presence  of  much   mucus,   involvement  of  the  large  bowel. 

Membranous  Enteritis. — This  term  has  been  applied  to 
two  conditions  :  (i)  A  true  croupous  enteritis,  which  is  asso- 
ciated with  the  formation  of  a  false  membrane,  and  which 
is  seen  in  cachectic  states,  in  acute  infectious  diseases,  and 
as  a  result  of  mineral  poisoning.  (2)  Mucous  colic,  or 
mucous  colitis,  a  chronic  form  of  colitis  usually  occurring 
in  women  of  a  marked  nervous  temperament,  and  charac- 
terized by  paroxysms  of  severe  pain  and  the  discharge  of 
gray,  translucent  casts  which,  however,  are  not  membranous, 
but  mucoid  in  character. 

Diagnosis. — Dysentery. — The  small  mucous  and  blood 
discharges  and  the  severe  tenesmus  will  indicate  dysentery. 

Ileocolitis. — This  disease  may  be  separated  from  simple 
enteritis  by  the  continued  high  fever,  more  frequent  dis- 
charges, the  presence  of  blood  and  mucus,  the  tenesmus, 
and  the  greater  prostration. 

Peritonitis. — This  disease  is  readily  distinguished  from 
enteritis  by  the  more  intense  pain  and  tenderness,  the 
greater  tympany,  the  marked  constitutional  disturbance, 
the  constipation,  and  the  immobility  of  the  patient. 

Typhoid  Fever. — The  gradual  onset,  nose-bleed,  splenic 
enlargement,  characteristic  fever,  Widal  reaction,  and  erup- 
tion will  lead  to  the  recognition  of  typhoid  fever. 

Prognosis. — Favorable  in  uncomplicated  cases.  Chronic 
diarrhea  often  persists  for  many  years  and  is  very  resistant 
to  treatment. 

Treatment. — Acute  Diarrhea  in  Ad^dts. — Rest  in  bed 
and  the  substitution  of  bland  nourishment  for  the  ordinary 
diet  are  all  that  is  required  in  many  cases.  Boiled  milk, 
milk  and  arrow-root,  and  mutton,  veal,  or  chicken  broth 
are  suitable  foods.  If  the  patient  is  seen  at  the  outset  and 
there  is  reason  to  believe  that  irritant  material  is  still  pres- 
ent in  the  bowel,  it  is  advisable  to  administer  an  unirritating 
purgative,  such  as  castor  oil,    Epsom  salts,  or    fractional 


INTESTINAL   CATARRH.  69 

doses  of  calomel.  Occasionally  a  second  dose  of  the  purga- 
tive may  be  given  with  benefit.  Externally,  stupes  or  sina- 
pisms are  frequently  efficacious.  If  the  diarrhea  continues, 
opium  and  mild  astringents,  like  bismuth  subnitrate  and 
chalk,  are  indicated.  They  may  be  combined  advantage- 
ously with  antiseptics,  as  in  the  following  formulas : 

R.    Morphinse  sulphatis gi"'  j 

Salol gr.  XXX 

Bismuthi  subnitratis ^ss. — M. 

Fiant  chartulae  No.  xij. 

SiG. — One  powder  every  three  hours. 

R.    Bismuthi  subsalicylatis 3iss 

Cretae  praeparatae ^iiss 

Tincturae  opii  camphoratae fjj 

Pulveris  acaciae q.  s. 

Aquae  cinnamomi q.  s.  ad  f5vj. — M. 

SiG. — A  tablespoonful  every  three  hours. 

Chronic  Diarrhea. — The  cause  must  be  ascertained  and 
removed,  if  possible.  The  diet,  clothing,  habits,  occupa- 
tion, and  mode  of  living  of  the  patient  should  receive  care- 
ful attention.  No  definite  rules  can  be  laid  down  in  refer- 
ence to  the  diet.  When  the  disease  is  not  very  severe  and 
is  confined  for  the  most  part  to  the  colon,  a  selected  mixed 
diet  may  be  allowed.  Many  patients  do  well  upon  an 
exclusive  milk  diet.  Foods  that  are  bulky  and  leave  much 
residue  are  always  inadmissible. 

Protection  of  the  body  against  chilling  is  of  vital  impor- 
tance. Woolens  should  be  worn  next  to  the  skin.  A 
snugly  fitting  abdominal  bandage  may  be  worn  as  an  addi- 
tional safeguard.  Rest  in  bed  is  sometimes  essential. 
When  the  general  nutrition  is  not  too  much  impaired,  a 
change  of  air  and  scene  may  prove  very  beneficial. 

Mineral  astringents,  especially  bismuth  subnitrate  (30  to 
40  grains),  silver  nitrate  (J  to  \  grain),  copper  sulphate  (^  to 
I  grain),  and  lead  acetate  (i  to  3  grains)  are  of  service. 

Intestinal  antiseptics — salol,  bismuth  salicylate,  beta- 
naphthol-bismuth — are  useful  adjuvants.  Opium  is  often 
required  in  acute  exacerbations.  When  the  disease  is  sit- 
uated chiefly  in  the  colon,  irrigation  of  the  bowel  two  or 


70  DISEASES   OF  THE  DIGESTIVE   SYSTEM. 

three  times  a  week  with  a  solution  of  silver  nitrate  (lO  to 
20  grains  to  i  pint)  is  especially  to  be  recommended. 

Acute  Diarrhea  in  hifants. — The  first  indication  is  to  with- 
draw the  milk  at  once,  and  to  withhold  it  for  several  days  or 
until  the  stools  become  quite  natural.  Indeed,  in  many  cases 
it  is  well  to  suspend  all  nourishment  for  the  first  twenty-four 
hours,  allowing  nothing  by  the  mouth  but  barley-water  or 
plain  boiled  water.  Subsequently,  albumin-water,  fresh 
beef-juice,  veal  broth,  or  a  liquid  peptone  preparation  may 
be  given  in  lieu  of  milk.  Milk  feeding  should  always  be 
resumed  very  gradually.  Absolute  rest  in  the  recumbent 
position  is  essential.  Removal  to  the  seashore  or  mountains 
is  often  of  the  greatest  benefit. 

To  remove  irritant  matter  from  the  bowel,  castor  oil  or 
calomel  should  be  given,  preferably  the  latter  when  the 
stomach  is  sensitive.  In  most  cases  it  is  necessary  to  fol- 
low the  purge  with  a  sedative  astringent  like  bismuth  sub- 
nitrate  or  chalk.  From  5  to  10  grains  of  one  of  these  drugs 
may  be  given  every  two  or  three  hours  with  an  intestinal 
antiseptic  (salol,  beta-naphthol-bismuth,  bismuth  salicylate) ; 
some  such  combination  as  the  following  may  be  ordered : 

R.     Bismuthi  subnitratis „    .     [^ij-iv 

Salol      gr.  xxiv 

Misturse  cretse      f^iij- — M. 

SiG. — A  teaspoonful  every  two  hours. 

A  more  active  astringent,  like  tannalbin  or  tannigen  (2  to 
3  grains),  may  be  given  in  addition  to  the  bismuth  sub- 
nitrate  or  chalk  when  the  discharges  are  exceedingly  pro- 
fuse and  watery. 

Opium  is  often  of  great  value,  but  extreme  caution  must 
be  exercised  in  its  use.  It  is  called  for  when  the  diarrhea 
continues  in  spite  of  the  thorough  unloading  of  the  bowel 
and  the  administration  of  mild  astringents.  From  3  to  5 
minims  of  paregoric  may  be  given  every  two,  three,  or  four 
hours,  according  to  circumstances.  When  the  stomach  is 
unretentive,  laudanum  (i  to  2  minims)  may  be  given  by 
enema. 


ACUTE   ILEOCOLITIS.  7 1 

ACUTE  ILEOCOLITIS. 

Definition. — An  acute  inflammatory  disease  involving 
the  ileum  and  colon  and  affecting  especially  the  lymph- 
follicles. 

Ktiology. — It  occurs  most  frequently  in  artificially  fed 
children.  Warm  weather  and  bad  hygienic  surroundings 
are  important  predisposing  factors.  It  sometimes  follows 
acute  infections,  like  measles. 

Micro-organisms  undoubtedly  play  an  important  role  in 
the  process.  In  a  number  of  instances  the  Bacillus  dysen- 
teriae  of  Shiga  has  been  recognized. 

Pathology. — The  mucous  membrane  is  swollen  and 
edematous.  The  solitary  and  agminated  glands  are  much 
enlarged  and  often  ulcerated.  In  some  cases  the  colon  is 
covered  with  a  pseudomembrane. 

Symptoms. — The  chief  features  are  pronounced  fever 
(i02°  to  104°  F.),  abdominal  distention  and  tenderness, 
tenesmus,  frequent  small  stools  of  a  greenish-yellow  color 
and  mixed  with  mucus  and  blood,  and  sometimes  with 
membranous  shreds.  There  is  rapid  loss  of  weight  and 
strength.  Death  is  frequently  preceded  by  delirium,  stupor, 
convulsions,  and  coma  (spurious  hydrocephalus). 

Diagnosis. — The  differential  diagnosis  between  ileo- 
colitis and  catarrhal  enteritis  has  already  been  considered. 

Cholera  infantum  may  be  recognized  by  the  rapid  onset, 
constant  vomiting,  profuse  serous  stools,  great  thirst,  high 
rectal  temperature,  and  rapidly  developing  collapse. 

Prognosis.  —  Grave;  mild  cases  recover  in  from  two  to 
three  weeks.  Strength  is  regained  slowly  and  relapses  are 
common. 

Treatment. — This  is  much  the  same  as  that  of  acute 
catarrhal  enteritis.  A  change  of  air  is  very  desirable.  Stim- 
ulants are  often  required.  From  10  to  20  minims  of  whisky 
may  be  given  every  two,  three,  or  four  hours.  Intestinal 
irrigation  is  an  important  part  of  the  treatment.  Twice  a 
day  the  colon  should  be  thoroughly  flushed  with  sterile 
water  containing  a  dram  of  benzoate  of  sodium  to  the  pint. 
After   the   irrigation  an  enema  of  thin   mucilage  (2   fluid- 


72  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

ounces)  and  bismuth  subnitrate  (2  drams)  may  be  given 
every  three  or  four  hours.  Extreme  tenesmus  is  some- 
times relieved  by  small  suppositories  containing  ^  of  a  grain 
of  cocain  (Rotch). 

CHOLERA  INFANTUM* 

Definition. — An  acute  gastro-intestinal  affection  char- 
acterized by  severe  choleriform  symptoms.  Compared  with 
acute  catarrhal  enteritis  and  ileocolitis,  it  is  a  rare  disease. 

l^tiology. — Hot  weather,  faulty  feeding,  bad  hygienic 
surroundings,  dentition,  and  indigestion  are  important  pre- 
disposing factors.  The  disease  is  probably  excited  by  a 
specific  micro-organism. 

Pathology. — Beyond  a  slight  catarrh  of  the  gastro- 
intestinal tract  there  are  no  gross  lesions.  The  grave  con- 
stitutional symptoms  are  no  doubt  due  to  the  absorption  of 
a  bacterial  poison. 

Symptoms. — The  symptoms  develop  rapidly.  Vomit- 
ing and  purging  begin  almost  simultaneously  and  become 
incessant.  The  stools  are  thin  and  watery  and  have  a 
musty  odor  and  an  alkaline  reaction.  Thirst  is  intense; 
there  is  great  restlessness ;  the  pulse  is  rapid  and  feeble ; 
the  surface  temperature  is  low,  but  the  rectal  temperature  is 
very  high  (105°  to  106°  F.) ;  the  urine  is  almost  suppressed. 
Collapse  soon  follows,  and  is  indicated  by  pinched  features, 
hollow  ^y^^y  sunken  fontanel,  pallid  skin,  and  cold  surface. 
Even  at  this  time  a  reaction  may  set  in,  but  in  the  large 
majority  of  cases  death  results  in  from  twenty-four  to  forty- 
eight  hours  from  exhaustion.  The  end  may  be  char- 
acterized by  the  symptoms  of  spurious  hydrocephalus — ■ 
delirium,  stupor,  convulsions,  and  coma.  As  these  nervous 
phenomena  are  unassociated  with  any  cerebral  lesion,  they 
are  probably  toxemic. 

Prognosis. — The  prognosis  is  very  bad.  The  outlook 
is  more  favorable  when  the  child  has  survived  the  severe 
symptoms  of  the  first  two  days.     Recovery  is  always  tedious. 

Treatment. — The  stomach  should  be  washed  out  with 
warm   water,   and   the   bowel    irrigated   with    cold   water. 


DYSENTERY.  73 

At  first  nothing  should  be  given  by  the  mouth  except 
sterilized  ice-cold  water  and  iced  brandy  or  champagne. 
When  the  stomach  is  wholly  unretentive,  stimulants 
should  be  given  hypodermically.  Hot  packs  (101.4°  F.) 
are  very  useful  in  combating  collapse.  In  urgent  cases 
normal  salt  solution  (40  grains  to  the  pint)  should  be  used 
subcutaneously,  from  2  to  3  ounces  being  injected  three  or 
four  times  daily.  If  vomiting  and  purging  still  continue, 
small  doses  of  morphin  and  atropin  should  be  administered 
hypodermically.  Holt  gives  j^-^  of  a  grain  of  morphin  with 
-g^  of  a  grain  of  atropin  for  a  child  one  year  old,  and  re- 
peats the  dose,  if  necessary. 

After  vomiting  has  ceased,  barley-water,  albumin-water, 
and  fresh  beef-juice  may  be  given  by  the  mouth.  Milk 
feeding  should  always  be  resumed  very  gradually. 

DYSENTERY, 

Definition. — An  acute  or  chronic  inflammatory  disease 
of  the  colon,  manifested  clinically  by  abdominal  pain,  tenes- 
mus, and  the  frequent  passage  of  small  stools  containing 
mucus  and  blood. 

Varieties. — (i)  Catarrhal;  (2)  amebic;  (3)  bacillary. 

Ktiology. — (i)  Warm  chmates  and  warm  weather;  (2) 
bad  hygienic  surroundings;  (3)  ingestion  of  irritating  food; 
(4)  exposure  to  cold  and  wet;  (5)  cachectic  states — are  the 
predisposing  factors. 

The  catarrhal  form  is  usually  sporadic  and  appears  to 
have  no  specific  etiology.     It  is  common  in  temperate  zones. 

The  amebic  form  is  due  to  the  Amoeba  coli,  an  organism 
from  three  to  five  times  the  size  of  a  red  blood-cell,  consist- 
ing of  a  central  mass  of  granular  protoplasm  surrounded  by 
a  narrow  rim  of  clear  protoplasm.  It  may  be  endemic  or 
sporadic. 

In  the  bacillary  form  the  pathogenic  agent  is  the  bacillus 
of  Shiga,  a  motile,  flagellate  rod  belonging  to  the  colon- 
typhoid  group  of  bacilli  and  possessing  pronounced  agglu- 
tinating properties.  Bacillaiy  dysentery  is  commonly  epi- 
demic, though  it  may  be  sporadic. 


74  DISEASES   OF   THE  DIGESTIVE   SYSTEM. 

While  the  amebic  and  bacillary  forms  are  frequently 
encountered  in  temperate  climates,  they  are  especially  preva- 
lent in  the  tropics. 

In  the  majority  of  instances  dysentery  is  a  water-borne 
disease. 

Pathology. — In  the  catarrhal  form  the  mucous  mem- 
brane of  the  colon  is  red,  swollen,  and  edematous.  Follicu- 
lar ulceration  is  sometimes  seen. 

The  amebic  form  is  marked  by  great  swelling  and  infil- 
tration of  the  mucosa  and  serpiginous  ulcers  with  irregular 
outlines  and  undermined  edges.  Abscess  of  the  liver  occurs 
in  about  20  per  cent,  of  the  cases.  In  bacillary  dysentery 
the  inflammation  is  often  diphtheritic.  Ulcers  are  also 
found,  but,  unhke  those  of  the  amebic  form,  they  begin  in 
the   mucosa  and  extend   regularly  into  the   deeper  coats. 


Fig.  2. — AmcEba  coli. 

The  bacillus  is  found  with  great  difficulty  in  the  chronic 
cases.     Abscess  of  the  liver  is  uncommon. 

Symptoms.  —  Catawhal  Dysentery.  —  Moderate  fever 
(ioi"-i03°  F.),  abdominal  pain,  tenderness  over  the  colon, 
constant  desire  to  defecate,  prostration,  tenesmus,  and  the 
passage  of  numerous  small  stools  containing  mucus  and 
blood.  Recovery  usually  follows  in  from  a  week  to  ten 
days.  The  disease  occasionally  becomes  chronic.  Com- 
plications are  rare. 

Amebic  Dysentery. — In  this  form  the  onset  is  more  grad- 
ual, fever  is  not  so  high,  tenesmus  is  less  marked,  and  the 
discharges  contain  living  amebae.  In  favorable  cases  the 
symptoms  abate  in  from  six  to  twelve  weeks.  In  the 
majority  of  cases,  however,  the  course  of  the  disease  is 
essentially  chronic,  and  marked  by  periodic  recrudescences. 

The  chief  features  of  the  chronic  form  are  dull  abdominal 


DYSENTERY.  75 

pain,  tenderness  over  the  colon,  frequent  stools  consisting 
of  scybalous  masses  covered  with  tenacious  mucus  and 
perhaps  with  blood  and  pus.  Slight  tenesmus,  and  ulti- 
mately extreme  anemia  and  emaciation.  Death  usually 
results  from  complications,  the  most  common  of  which  is 
abscess  of  the  liver. 

Bacillary  Dysentery. — The  symptoms  begin  acutely,  and 
are  often  severe.  In  addition  to  mucus  and  blood,  the 
stools  may  contain  false  membrane  and  gangrenous  tis- 
sue. Tympanites  is  common.  Typhoid  symptoms — delir- 
ium, stupor,  subsultus  tendinum,  etc. — are  also  frequent. 
Asthenia  and  emaciation  rapidly  develop.  The  blood-serum 
yields  an  agglutination  reaction  with  the  Shiga  bacillus.  In 
some  epidemics  the  mortality  has  reached  40  per  cent. 
Death  usually  results  from  exhaustion  or  collapse,  and  very 
rarely  from  abscess  of  the  liver  or  other  complications. 
Occasionally  the  disease  loses  its  acute  character  and 
becomes  chronic. 

Complications  and  Sequels. — Hepatic  abscess  is  the 
most  common  comphcation.  It  occurs  chiefly  in  the  amebic 
form.  Peritonitis  from  perforation  or  from  extension  of 
the  inflammation,  hemorrhage,  multiple  neuritis,  and  intes- 
tinal stricture  are  rare  accidents. 

Diagnosis. — Acute  Catarrhal  Enteritis. — In  this  disease 
tenesmus  is  absent ;  the  stools  are  not  bloody  and  mucoid, 
and  are  neither  so  frequent  nor  so  scanty. 

Intussusception. — The  abrupt  onset,  persistent  vomiting, 
and  presence  of  a  sausage-shaped  tumor  in  the  abdomen 
will  generally  make  the  diagnosis  clear. 

Treatment. — Rest  in  bed  is  imperative.  In  acute  cases 
the  diet  should  be  liquid — milk  with  lime-water,  animal 
broths,  and  egg-white.  In  chronic  cases  soft-boiled  eggs, 
pulled  bread,  steamed  rice,  oysters,  and  tender  meats  may 
be  allowed. 

The  stools  should  be  immediately  disinfected. 

An  unirritating  purgative  (Epsom  salts  or  calomel)  is 
nearly  always  indicated  at  the  onset.  Subsequently,  opium 
should  be  given  to  check  peristalsis  and  to  relieve  tenesmus. 
It   may  be   given  hypodermically  in  the  form  of  morphin, 


76  DISEASES   OF  THE  DIGESTIVE   SYSTEM. 

or  by  the  bowel  in  form  of  starch-water  (^  fluidounce)  and 
laudanum  (lo  to  20  drops)  injections.  Turpentine  stupes  or 
sinapisms  afford  relief  Persistent  tenesmus  is  sometimes 
controlled  by  ice  suppositories  or  iodoform  suppositories 
(2  to  5  grains).  Internally,  bismuth  subnitrate  (30  to  40 
grains),  with  antiseptics  like  beta-naphthol-bismuth  (10 
grains),  salol  (5  grains),  or  benzonaphthol  (5  to  10  grains), 
is  useful.     The  following  combination  is  often  of  value : 

^.    Pulveris  ipecacuanhse  et  opii    ....    •  ^ss 

Bismuthi  subnitratis ^ss 

Bismuthi  beta-naphthol ^j. — M. 

Fiant  chartulse  No.  xij. 

SiG. — One  powder  every  two  hours. 

In  many  cases  the  adynamia  is  so  pronounced  that  stim- 
ulants must  be  used  freely. 

Two  special  methods  of  treatment  have  been  found  effica- 
cious— that  by  ipecac  and  that  by  salines : 

Ipecac. — On  the  first  day  a  single  large  dose  of  from  30 
to  40  grains  of  powdered  ipecac  is  given  stirred  up  in 
water.  Subsequently  from  10  to  20  grains  are  given  daily 
for  three  or  four  days.  To  prevent  emesis,  laudanum  (15 
to  20  drops)  is  given  twenty  minutes  in  advance  of  the 
ipecac.  A  sinapism  is  applied  to  the  epigastrium,  and  abso- 
lute quiet  is  enjoined.  A  successful  issue  is  indicated  by 
the  appearance,  usually  within  twenty-four  hours,  of  a 
copious  black  stool. 

Salines. — -A  purgative  dose  of  magnesium  sulphate  is 
administered  at  once,  and  after  the  bowel  has  been  thor- 
oughly emptied,  small  doses  (i  dram)  are  given  several  times 
a  day,  preferably  in  combination  with  aromatic  sulphuric 
acid,  as  in  the  following  formula : 

Ijt.    Magnesii  sulphatis ^iss 

Acidi  sulphurici  aromatici f^ij 

Aquas  cinnamomi q.  s.  ad  f5vj. — M. 

SiG. — A  tablespoonful  four  times  a  day. 

This  treatment  should  be  continued  for  several  days  after 
the  stools  have  ceased  to  be  dysenteric. 

Chronic  Dysentery. — Bismuth  subnitrate  (^  dram)  with  in- 
testinal antiseptics  is  of  value.     Stengel    and  others    have 


CHOLERA   MORBUS.  7/ 

found  sulphur  very  serviceable  in  amebic  dysentery.  Ten 
grains  should  be  given  three  or  four  times  a  day,  combined 
with  a  small  amount  of  opium. 

Intestinal  irrigation  with  solutions  of  silver  nitrate  (lo  to 
30  grains  to  I  pint  of  cold  water)  is  of  the  greatest  benefit. 
These  injections  should  be  given  two  or  three  times  a  week, 
the  fluid  being  introduced  very  gently  and  slowly  by  means 
of  a  fountain-syringe.  When  the  rectum  is  very  irritable,  it 
is  advisable  to  inject  a  small  quantity  of  cocain  solution 
(4  per  cent.)  before  introducing  the  irrigator.  In  amebic 
dysentery  warm  injections  of  quinin  (i  :  5000  to  i  :  2000), 
creolin  (^i  per  cent,  mixtures),  and  benzoyl-acetyl  peroxid 
(i  :  1000)  have  also  been  found  efficacious. 

CHOLERA  MORBUS* 

(English  Cholera;  Cholera  Nostras.) 

Definition. — An  acute  sporadic  disease,  resembling 
Asiatic  cholera,  but  not  excited  by  the  comma  bacillus  of 
Koch. 

Ktiology. — The  summer  season  predisposes,  and  irri- 
tating food,  as  unripe  fruit,  and  a  sudden  change  of  tempera- 
ture are  the  usual  exciting  causes.  An  organism  resem- 
bling the  bacillus  of  true  cholera  is  often  present  in  the 
discharges. 

Symptotns.^ — There  are  intense  cramps  in  the  stomach, 
vomiting  and  purging  of  bilious  material,  thirst,  moderate 
fever,  and  great  prostration.  In  severe  cases  the  discharges 
become  serous,  and  symptoms  of  collapse  develop. 

Diagnosis. — Asiatic  Cholera. — In  this  disease  there  is 
often  no  history  of  dietetic  indiscretions ;  etiologic  relation 
with  another  case  can  usually  be  established ;  the  stools 
have  a  characteristic  "  rice-water "  appearance ;  there  are 
painful  cramps  in  the  legs ;  and  the  typical  cholera  bacillus 
is  present. 

Mineral  Poisoning. — The  history,  burning  pain  in  the  gul- 
let and  rectum,  erosion  of  the  mouth  and  throat,  and 
mucous,  bloody  discharges  will  usually  lead  to  a  correct 
diagnosis. 


78  .  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

Prognosis. — Favorable.  Death  rarely  occurs,  except  in 
old  or  debilitated  subjects.  The  duration  is  usually  from 
twenty-four  to  forty-eight  hours. 

Treatment. — The  hypodermic  injection  of  morphin  (1 
grain)  and  atropin  (y^Q-  grain)  is  usually  necessary.  Hot 
applications  to  the  abdomen  are  also  useful.  Thirst  is  best 
reheved  by  cracked  ice.  Calomel  in  fractional  doses  serves 
to  allay  vomiting  and  to  rid  the  bowel  of  irritating  matter. 

In  many  cases  an  anodyne  mixture  like  the  following  will 
act  admirably : 

5k.     Spiritus  camphorge      f^ss 

Olei  caryophylli .    tl^xx 

Chloroformi fgiij 

Tinctuiae  opii  deodorati 

Tincturse  capsici aa  f^ij. — M. 

SiG. — Shake   well.      Thirty  to  forty  drops   in  water  every  half 
hour  to  two  hours,  as  required.  (H.  C.  Wood.) 

Collapse  will  require  hot  baths,  diffusible  stimulants  (am- 
monia, ether,  brandy),  and  subcutaneous  injections  of  salt 
solution. 

APPENDICITIS* 

(Typhlitis;  Perityphlitis.) 

Definition. — An  inflammation  of  the  appendix  vermi- 
formis. 

Pathology. — There  are  three  varieties  :  Catarrhal,  ulcer- 
ative, and  interstitial. 

Catari'hal  Appendicitis. — In  mild  cases  the  appearances 
are,  no  doubt,  similar  to  those  observed  in  catarrh  elsewhere, 
but  in  severe  cases  the  wall  of  the  appendix  is  infiltrated 
with  round-cells,  and  the  mucous  membrane  is  denuded  of 
epithelium  and  presents  a  granular  surface.  This  latter 
condition  may  eventuate  in  septic  peritonitis,  chronic  appen- 
dicitis with  relapses  (recurrent  appendicitis),  or  union  of  the 
granulating  surfaces  with  complete  obliteration  {appendicitis 
obliterans). 

Ulcerative  Appendicitis. — In  this  type  the  wall  of  the  ap- 
pendix is  the  seat  of  a  more  or  less  localized  ulcer.  It  may 
be  associated  with  the  presence  of  fecal  concretion  or   a 


APPENDICITIS.  79 

foreign  body,  or  it  may  be  the  result  of  typhoid  or  tuber- 
cular infection. 

Interstitial  Appendicitis. — In  this  form  the  wall  of  the  ap- 
pendix is  the  seat  of  a  necrosis,  which  is  not  infrequently 
gangrenous.  It  may  be  primary,  infection  taking  place 
through  the  lymphatics,  or  secondary  to  the  catarrhal  or 
ulcerative  form.  It  terminates  in  perforation,  thereby  excit- 
ing a  most  virulent  type  of  peritonitis. 

Appendicitis  is  always  due  to  the  action  of  pathogenic 
bacteria,  the  chief  offenders  being  the  Bacillus  coli  com- 
munis. Streptococcus  pyogenes.  Staphylococcus  pyogenes 
aureus,  typhoid  bacillus,  and  tubercle  bacillus.  Of  these, 
the  Bacillus  ccli  communis,  a  natural  habitant  of  the  bowel, 
is  most  commonly  present.  Under  ordinary  conditions  it  is 
harmless,  but  when  the  circulation  of  the  appendix  is  inter- 
fered with  from  any  cause  or  the  coats  of  the  tube  are 
abraded,  infection  is  liable  to  arise. 

Ktiology. — It  is  more  common  in  males  than  In  females. 
It  is  most  frequent  between  the  fifteenth  and  thirtieth  years. 
Exposure,  errors  in  diet,  intestinal  catarrh,  traumatism,  and 
the  lodgement  in  the  appendix  of  fecal  concretions  or  foreign 
bodies  predispose  to  the  disease.  It  may  follow  some  infec- 
tion like  typhoid  fever,  influenza,  or  tuberculosis.  It  may 
be  induced  by  twisting  of  the  appendix. 

Symptoms. — (i)  Sudden  pain,  often  general  at  first,  but 
later  most  marked  in  the  right  iliac  region.  (2)  Circum- 
scribed tenderness,  most  frequently  detected  over  McBur- 
ney's  point — a  point  midway  on  a  line  between  the  umbilicus 
and  the  anterior  superior  iliac  spine.  (3)  Fever,  ranging 
between  100°  and  103°  F.  (4)  Localized  rigidity  in  the 
right  iliac  fossa,  or  the  presence  of  a  definite  tumor.  (5) 
Dorsal  decubitus  with  the  right  thigh  flexed.  (6)  Gastro- 
intestinal disturbances — anorexia,  nausea,  vomiting,  consti- 
pation, or  rarely  diarrhea. 

Terminations. — Resolution,  general  peritonitis,  and 
localized  abscess.  The  location  of  the  abscess  depends  on 
the  position  of  the  appendix.  It  may  be  found  in  either  of 
the  lower  quadrants  or  beneath  the  diaphragm  (subphrenic 
abscess).      The  pus  may  be  discharged  through  the  ab- 


8o  DISEASES   OF  THE  DIGESTIVE   SYSTEM. 

dominal  walls,  the  bowel,  bladder,  or  vagina,  or  it  may 
escape  into  the  tissues  of  the  lumbar  region  or  thigh.  Ap- 
pendicitis occasionally  excites  hepatic  abscess,  the  infection 
being  carried  through  the  portal  vein. 

Diagnosis. — Typhoid  Fever. — The  gradual  onset,  char- 
acteristic temperature-curve,  epistaxis,  mental  hebetude, 
diarrhea,  splenic  enlargement,  and,  later,  the  rash  and 
Widal  reaction  will  indicate  typhoid  fever. 

Renal  Colic. — This  may  be  recognized  by  the  absence  of 
fever  and  of  local  rigidity,  and  the  presence  of  hematuria. 

Acute  Inflammation  of  the  Gall-bladder. — Pain  and  tender- 
ness in  the  right  hypochondrium,  a  smooth,  mobile  tumor, 
and  a  history  of  biliary  coHc  would  suggest  this  condition. 

Tubal  Disease. — The  history  and  results  of  pelvic  exami- 
nation will  usually  prevent  an  error  in  diagnosis. 

Prog"nosiS. — The  prognosis  depends  on  the  type.  The 
average  mortality  is  about   14  per  cent. 

Treatment. — The  patient  should  be  kept  in  bed  at 
absolute  rest.  The  diet  should  be  restricted  to  small  quan- 
tities of  bland  liquids — milk,  albumin-water,  and  broths. 
Constipation  is  best  relieved  by  enemas  of  warm  water. 
Locally,  cold  or  heat  may  be  applied,  according  to  the  sen- 
sations of  the  patient.  If  the  pain  is  very  severe,  morphin 
may  be  administered  hypodermically ;  only  the  minimum 
amount  necessary  to  afford  a  measure  of  relief  is  to  be  used, 
however,  as  by  obscuring  the  symptoms,  the  drug  prevents 
an  accurate  study  of  the  progress  of  the  case. 

An  operation  should  be  urged — (i)  At  once  in  all  cases 
in  which  the  onset  is  very  severe,  the  symptoms  indicating 
special  severity  being  marked  right-sided  tenderness  and 
rigidity,  distention,  and  vomiting,  with  or  without  fever; 
(2)  in  cases  of  moderate  severity  which  manifest  no  improve- 
ment after  the  lapse  of  forty-eight  hours ;  and  (3)  in  cases  in 
which  the  symptoms,  after  decided  improvement,  return; 
On  the  contrary,  operation  is  rarely  required,  at  least  during 
the  attack — (i)  In  cases  of  a  mild  type,  in  which  the  pain  is 
Unaccompanied  by  rigidity,  distention,  nausea,  or  vomiting ; 
and  (2)  in  cases  of  moderate  severity  in  which  improvement 
is   noticeable  within  forty-eight  hours.      Operation   during 


INTESTINAL    OBSTRUCTION.  8 1 

the  quiescent  stage,  when  the  element  of  danger  is  almost 
entirely  removed,  is  to  be  recommended — (i)  When  an 
acute  attack  has  been  followed  by  persistent  tumefaction 
and  tenderness,  intestinal  disturbances,  or  impairment  of  the 
general  health ;  (2)  when  there  have  already  been  two 
attacks,  even  of  moderate  severity ;  and  (3)  when  mild 
attacks  occur  with  such  frequency  as  to  induce  disability. 


INTESTINAL  OBSTRUCTION. 

(Ileus.) 

Intestinal  obstruction  may  be  either  acute  or  chronic. 
The  chief  causes  of  the  acute  form  are:  (i)  Strangulation; 
(2)  intussusception  ;  (3)  volvulus ;  (4)  impaction  of  foreign 
bodies  or  gall-stones  ;  (5)  paresis  of  the  intestine ;  (6)  con- 
genital malformation  or  stricture. 

CiiroJiic  obstruction  may  be  due  to — (i)  Impaction  of  feces  ; 
(2)  stricture ;  (3)  tumors  of  the  bowel  or  of  neighboring 
organs. 

Symptoms  of  Acute  Obstruction. — (i)  Sudden  ab- 
dominal pain — at  first  paroxysmal,  but  later  continuous  ; 
(2)  constipation,  soon  becoming  absolute;  (3)  vomiting,  per- 
sistent and  ultimately  of  a  stercoraceous  character ;  (4)  ab- 
dominal distention  ;  (5)  visible  peristaltic  waves  ;  (6)  col- 
lapse, indicated  by  pinched  features,  sunken  eyes,  a  cold, 
clammy  surface,  and  a  frequent  feeble  pulse. 

Symptoms  of  Chronic  Obstruction. — The  symptoms 
usually  develop  gradually.  Acute  symptoms  may  appear, 
however,  when  the  occlusion  becomes  complete.  The  chief 
features  are  intractable  constipation,  colicky  pains,  distention 
of  the  abdomen,  and  gradual  failure  of  health.  The  stools 
may  be  ribbon-shaped  or  in  the  form  of  scybalous  masses, 
and  are  sometimes  coated  with  mucus  and  blood.  Vomit- 
ing is  not  common. 

Diagnosis. — Early  vomiting,  slight  distention,  suppres- 
sion of  urine,  and  rapid  collapse  point  to  an  obstruction  high 
in  the  small  intestine. 

Acute  Generalized  Peritonitis. — The  history,  early  appear- 


B2  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

ance  of  fever  and  of  diffuse  tenderness,  signs  of  effusion,  and 
absence  of  stercoraceous  vomiting  will  indicate  peritonitis. 

Strangulation. — Tliis  often  occurs  in  external  hernia,  when 
it  can  be  recognized  by  an  examination  of  the  inguinal, 
femoral,  and  umbilical  rings. 

Internal  strangulation  is  very  common.  It  may  be  due 
to  the  slipping  of  a  coil  of  intestine  under  bands  of  adhe- 
sions, the  result  of  a  former  peritonitis,  or  under  Meckel's 
diverticulum  that  is  abnormally  attached  to  the  abdominal 
wall,  or  through  a  slit  in  the  omentum  or  mesentery,  the 
foramen  of  Winslow,  or  the  diaphragm.  It  usually  occurs 
in  young  adults  ;  there  is  often  a  history  of  injury  or  of  peri- 
tonitis, and  the  symptoms  are  very  acute. 

Intussusception  or  Invagination. — This  is  the  slipping  of  a 
portion  of  the  intestine  into  the  part  immediately  below  it. 
It  occurs  especially  in  children.  Its  exciting  cause  is  proba- 
bly irregular  peristalsis,  whereby  one  part  of  the  bowel  is 
constricted  while  the  adjoining  part  is  dilated.  The  usual 
seat  is  the  ileocecal  region. 

Multiple  invaginations  are  frequently  found  postmortem, 
which  have  resulted  from  the  irregular  peristalsis  occurring 
just  before  death;  they  possess  no  inflammatory  character- 
istics. In  invaginations  not  cadaveric  the  parts  are  injected, 
swollen,  and  covered  with  lymph. 

The  age  of  the  patient,  the  sudden  abdominal  pain,  the 
vomiting,  the  passage  with  tenesmus  of  mucus  and  bloody 
feces,  and  the  presence  of  a  sausage-shaped  tumor  in  the 
region  of  the  ascending  colon  are  the  diagnostic  features. 
Occasionally  the  invaginated  portion  can  be  felt  in  the 
rectum. 

Death  usually  results  from  gangrene,  peritonitis,  or  col- 
lapse. A  favorable  termination  sometimes  results  from  the 
escape  of  the  incarcerated  part,  or  by  a  sloughing  off  of 
the  strangulated  portion  and  adhesion  of  the  serous  surfaces. 

Volvulus  or  Twist  or  Knot  of  the  Bowel. — Volvulus  occurs 
most  commonly  in  middle-aged  men.  The  usual  seat  is  the 
sigmoid  flexure,  A  relaxed  and  lengthened  mesentery  is  a 
predisposing  factor.  It  cannot  be  recognized  with  certainty 
without  abdominal  section. 


INTESTINAL    OBSTRUCTION.  83 

Impaction  of  Foreign  Bodies. — Foreign  bodies  swallowed 
by  accident  or  design,  gall-stones,  or  enteroliths  may  cause 
acute  intestinal  obstruction.  The  history  may  aid  in  the 
diagnosis. 

Gall-stone  ileus  is  most  frequently  met  with  in  women 
after  the  fiftieth  year.  The  ileocecal  region  is  the  usual  seat 
of  the  obstruction. 

Paresis  of  the  Bowel. — This  occasionally  develops  idio- 
pathically  in  nervous  women.  It  may  also  result  from  peri- 
tonitis, an  abdominal  operation,  the  reduction  of  a  hernia,  or 
traumatism. 

Congenital  Malformation. — This  rare  form  of  obstruction 
usually  consists  in  an  imperforate  condition  of  the  anus  or 
rectum.     It  may  be  recognized  by  digital  examination. 

Impaction  of  Feces. — This  may  occur  at  any  age,  but  it  is 
most  often  seen  in  persons  past  middle  life.  The  usual  seat 
of  the  impaction  is  the  rectum  or  colon.  The  condition 
may  be  recognized  by  the  gradual  onset  of  the  symptoms, 
the  history  of  habitual  constipation,  and  by  the  presence  of 
a  fecal  mass  in  the  rectum  or  of  an  irregular,  painless, 
doughy  tumor  in  the  region  of  the  colon. 

Stricture  and  Tumors. — Cicatricial  contraction  may  re- 
sult from  syphihtic,  tuberculous,  or  dysenteric  ulceration. 
The  rectum  is  the  part  most  frequently  involved.  The 
most  common  tumor  of  the  bowel  is  cancer.  It  is  usually 
seated  in  the  rectum.  The  diagnosis  may  be  established 
by  the  history  of  the  case,  the  gradual  onset  of  obstructive 
symptoms,  impairment  of  health,  painful  defecation,  the  size 
and  form  of  the  stools,  the  presence  x>f  blood  and  pus  in  the 
stools,  and  the  results  of  a  physical  examination. 

Treatment. — Amte  Obstruction. — Food  by  the  mouth 
should  be  withheld.  Ice  may  be  given  to  quench  thirst. 
Nutritive  enemata  should  be  employed  in  the  weak.  Cathar- 
tics are  contraindicated.  Pain  is  best  relieved  by  warm  appli- 
cations and  the  administration  of  morphin  hypodermically. 
Washing  out  the  stomach  three  or  four  times  daily  is  rec- 
ommended for  the  persistent  vomiting.  Distention  of  the 
large  bowel  with  warm  water  or  gas  should  be  practised  in 
doubtful  cases  and  intussusception.     It  is  best  done  under 


84  DISEASES   OE   THE  DIGESTIVE   SYSTEM. 

anesthesia  with  the  patient  in  knee-elbow  position.  After 
failure  with  these  methods  operation  should  not  be  de- 
layed ;  the  earlier  its  performance,  the  greater  the  chance 
of  success. 

Chronic  Obstruction. — The  treatment  will  vary  with  the 
cause.     Surgical  interference  is  frequently  required. 

In  fecal  impaction  injections  of  warm  water,  of  oil  (4  to  6 
fluidounces),  or  of  aqueous  solutions  of  ox-gall  (2  drams  to 
I  pint)  are  efficient.  Sahnes  may  be  administered  by  the 
.mouth.  Massage  is  sometimes  useful.  Hard  rectal  accu- 
mulations may  have  to  be  removed  by  the  fingers  or  a 
suitable  scoop. 

ANIMAL  PARASITES- 
CESTODES  OR  TAPE-WORMS. 

Varieties. — Taenia  solium ;  Taenia  saginata ;  Bothrio- 
cephalus  latus  ;  Taenia  echinococcus. 

I/ife  History. — The  eggs  of  the  tape-worm  are  ingested 
by  animals  (the  intermediary  host),  and  embryos  or  prosco- 
lices  are  liberated  in  the  stomach ;  these  migrate  to  the 
muscles  or  organs,  where  they  become  transformed  into 
encysted  larvae  or  scolices.  The  encysted  larvae  are  known 
as  cysticerci  or  *'  measles."  When  flesh  infested  with  cysti- 
cerci  is  eaten  by  man  (the  host),  the  scolex  is  liberated,  fas- 
tens itself  to  the  mucous  membrane  of  the  bowel,  and 
rapidly  develops  into  a  mature  worm. 

Taenia  Solium. — This  worm  exists  in  the  larval  state  in  the 
hog.  The  mature  worm  is  two  or  three  yards  in  length. 
Its  head,  which  is  the  size  of  a  pin-head,  is  provided  with 
four  pigmented,  cup-like  suckers,  surrounded  by  a  double 
row  of  booklets,  and  is  attached  to  the  body  by  a  thread- 
like neck.  The  sexual  orifice  is  in  the  center  of  the  broad 
surface  of  the  segment.     This  parasite  is  rare  in  America. 

Taenia  Saginata  or  Mediocanellata. — The  larval  form 
occurs  in  the  ox.  The  mature  worm  is  five  or  six  yards  in 
length.  The  head  is  larger  than  that  of  the  Taenia  solium, 
and  has  four  large  suckers,  but  no  booklets.  The  segments 
are   fatter,  and   the   uterine  branches  are  finer  and  more 


ANIMAL   PARASITES.  85 

numerous  than  in  the  Taenia  solium.  It  is  the  common  tape- 
worm of  this  country. 

Bothriocephalus  Latus. — The  intermediate  host  is  some 
form  of  fish  (pike).  The  adult  worm  is  from  five  to  ten 
yards  in  length.  The  head  is  flattened  and  club-shaped, 
presents  two  groove-like  suckers,  but  is  without  booklets. 
This  worm  is  frequent  in  certain  parts  of  Europe,  but  it  is 
rare  in  America. 

Taenia  Echinococcus. — This  worm  in  its  adult  form  occurs 
in  the  intestine  of  the  dog ;  in  man  it  appears  only  in  the 
larval  condition  (see  Hydatid  Cysts  of  the  Liver). 

Sytnptotns. — In  many  cases  there  are  no  subjective 
symptoms.  Some  patients,  however,  present  the  symptoms 
of  dyspepsia,  buHmia,  colicky  pains,  progressive  emaciation, 
anemia,  and  certain  reflex  manifestations — vertigo,  palpita- 
tion, itching  of  the  nose,  spasms,  and  choreic  movements. 
The  diagnosis  rests  on  the  discovery  of  the  tenia  segments 
or  eggs  in  the  stools. 

The  bothriocephalus  may-produce  a  very  severe  anemia, 
which  has  been  ascribed  to  the  secretion  of  substances 
having  a  destructive  action  on  the  red  blood-cells. 

Treatment. — By  way  of  preparatory  treatment  it  is  ad- 
visable to  restrict  the  diet  for  a  day  or  two  to  liquids  and  to 
empty  the  bowel  as  completely  as  possible  by  saline  purges. 
The  best  anthelmintics  are  oleoresin  of  aspidium  {\  to  I 
dram),  pumpkin  seed  (2  to  3  ounces),  and  pelletierin  (5  to  8 
grains). 

R.     Oleoresinse  aspidii f^ss 

Pulveris  acaciae  et  sacchari  .    .  aa  q.  s. 

Aquae  cinnamomi q.  s.  ad  f^ij. — M. 

SiG.— One  tablespoonful,  to  be  repeated  if  necessary. 

A  purge  should  be  given  a  few  hours  after  the  anthel- 
mintic. The  treatment  is  successful  only  when  the  head  of 
the  worm  is  passed. 

NEMATODES  OR  ROUND-WORMS. 
Ascatis     IvUmbricoides     {Common     Rotmd-zvorm). — 
Round-worms  develop  from  eggs  which   have  entered  the 
body  through  water  or  food.     They  are  of  a  brownish  or 


S6  DISEASES   OF  THE  DIGESTIVE  SYSTEM. 

pinkish  color,  and  in  form  resemble  earth-worms.  They 
occupy  the  small  intestines,  but  occasionally  migrate,  en- 
tering the  stomach,  bile-ducts,  and  even  the  larynx.  They 
are  most  commonly  found  in  children. 

Symptoms. — Often  absent.  Sometimes  there  are  dys- 
pepsia, mucous  stools,  colicky  pains,  voracious  appetite, 
anemia,  and  reflex  nervous  phenomena — night-terrors,  grind- 
ing of  the  teeth,  pruritus  of  nose  and  anus,  choreic  move- 
ments, and  convulsions. 

Treatment. — Santonin  (|— J  grain);  wormseed  oil  (lo 
drops  in  capsule  or  on  sugar)  ;  fluid  extract  of  spigelia  (i  to 
3  fluidrams)  are  efficient  remedies.  The  anthelmintic  should 
be  followed  by  a  purge. 

5^.     Santonini gi"-  vj 

Hydrargyri  chloridi  mitis gr-  vj 

Sacchari gr.  xxiv. — M. 

Fiant  in  chartulse  No.  xij. 

SiG. — One  powder  morning  and  evening.  (Starr.) 

Oxyuris  Vermicularis  {Seat-iuon?i ;  Pin-zvomi). — Pin-- 
worms  are  from  one-eighth  to  one-half  inch  in  length.  They 
are  most  commonly  seen  in  children,  infection  probably  taking 
place  through  water  or  green  vegetables.  They  occupy  the 
rectum  and  colon,  and  are  often  present  in  great  numbers. 
They  produce  intense  itching,  particularly  at  night. 

Treatment. — Copious  injections  of  a  cold  infusion  of 
quassia  (i  ounce  to  i  pint)  or  of  a  solution  of  sodium  chlorid 
(i  dram  to  i  pint)  usually  prove  successful.  In  obstinate 
cases  anthelmintics  (santon  in  or  chenopodium)  should  be  given 
by  the  mouth.  Care  should  be  taken  to  prevent  reinfection 
with  the  eggs,  which  are  produced  in  large  numbers. 

Uncinaria  Duodenalis  (Ankylostoma  Duodenale) 
and  Uncinaria  Americana. — These  are  hook-worms  of 
the  genus  Uncinaria,  measuring  from  8  to  i6  mm.  in  length" 
The  former  prevails  in  the  old  world  and  the  latter  in 
America.     Their  habitat  is  the  small  intestine. 

Uncinariasis  or  ankylostomiasis  is  a  common  disease  in 
tropical  and  subtropical  countries.  In  temperate  regions  it 
prevails  chiefly  among  miners.  It  is  believed  that  the  para- 
sites may  enter  the  body  either  through  the  medium  of 
drinking  water  or  directly  through  the  skin.    Anemia,  more 


ANIMAL    PARASITES,  8/ 

or  less  severe,  is  the  chief  symptom.  There  is  nearly  always 
a  well-marked  eosinophilia.  Digestive  disturbances  may 
also  be  present.  The  diagnosis  rests  upon  the  discovery  of 
the  ova  in  the  stools. 

Treatment. — Thymol,  in  doses  of  30  grains,  repeated  in 
two  hours,  and  followed  by  a  purgative,  is  almost  a  specific. 

Filaria  Sanguinis  Hominis. — A  small  thread-like 
worm,  most  commonly  seen  in  warm  climates.  The  adult 
occupies  the  lymphatics,  and  the  female  brings  forth  a  great 
number  of  actively  motile  embryos,  which  soon  find  their 
way  into  the  blood-current.  It  is  a  curious  fact  that  the 
embryos  are  found  in  the  blood  only  at  night.  The  me- 
dium of  infection  is  the  mosquito,  which  probably  carries 
the  embryo  from  the  blood  to  the  drinking-water. 

Symptoms. — Chyluria,  hematuria,  elephantiasis,  and  lymph- 
scrotum  may  result  from  occlusion  of  the  lymphatic  vessels. 

Treatment. — Thymol  (3  to  5  grains)  and  methylene-blue 
(i  to  3  grains)  have  been  used,  but  they  are  rarely  effi- 
cacious. 

Trichina  Spiralis. — This  is  a  small  worm  derived  from 
the  hog.  Man  is  infected  by  eating  insufficiently  cooked 
pork  containing  the  encapsulated  larvae.  The  worm  is  set 
free  in  the  stomach,  where  it  develops  and  brings  forth  living 
embryos  in  immense  numbers.  These,  entering  the  bowel, 
soon  migrate  into  the  muscles,  where  they  develop,  coil 
themselves  up,  and  become  encapsulated.  Trichinous  cap- 
sules, impregnated  with  lime-salts,  are  visible  to  the  naked 
eye,  and  are   sometimes   detected  accidentally  at  autopsies. 

Symptoms  of  Trichiniasis  (Trichinosis). — No  decided  symp- 
toms develop  unless  the  parasites  have  been  ingested  in  large 
numbers.  In  well-marked  cases  gastro-intestinal  disturb- 
ances appear  on  the  second  or  third  day.  These  disturbances 
consist  in  colicky  pains,  nausea,  vomiting,  and  serous  diar- 
rhea. 

In  from  one  to  two  weeks  symptoms  of  an  acute  myositis 
develop,  characterized  by  severe  muscular  pains  and  sore- 
ness, edema,  beginning  in  the  face,  sweating,  and  fever. 
Hoarseness  and  dyspnea  may  occur  from  involvement  of 
the  larynx  and  diaphragm. 

Leukocytosis  is  marked,  the  eosinophihc  cells  being  espe- 


88  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

daily  Increased.  In  certain  cases  the  symptoms  closely 
resemble  those  of  typhoid  fever.  In  favorable  cases  recov- 
ery is  effected  in  from  two  to  eight  weeks. 

Diagnosis. — Typhoid  Fever. — The  history,  the  presence 
of  eosinophilia,  of  intense  muscular  soreness,  of  edema,  of 
parasites  in  the  stools  or  in  a  fragment  of  muscle  removed 
from  the  arm,  and  the  absence  of  a  typical  rash  and  of  the 
Widal  reaction  will  lead  to  a  correct  diagnosis. 

Muscular  Rheumatism. — The  history,  the  presence  of  gas- 
tro-intestinal  symptoms,  of  edema,  and  of  eosinophilia  will 
suggest  trichiniasis. 

Prognosis. — This  depends  upon  the  number  of  worms 
ingested.  Early  diarrhea  is  favorable.  The  mortality  ranges 
from  5  to  30  per  cent. 

Treatment. — The  most  efficient  prophylactic  measure 
is  the  thorough  cooking  of  all  pork  products.  In  the  first 
stage  cathartics  are  indicated.  Anthelmintics — santonin, 
aspidium,  and  thymol — have  been  recommended.  After  mi- 
gration, the  indications  are  to  relieve  pain  by  means  of  opiates, 
hot  baths,  and  warm  embrocations,  and  to  support  the 
strength  by  concentrated  liquid  diet  and  stimulants. 


DISEASES  OF  THE  PANCREAS. 

HEMORRHAGE  INTO  THE  PANCREAS. 

etiology. — Hemorrhage  into  the  pancreas  may  result 
from  traumatism.  It  may  be  due  to  passive  congestion,  to 
hemorrhagic  diseases  (scurvy,  purpura,  etc.),  or  to  acute 
infections.  It  is  very  commonly  associated  with  organic 
disease  of  the  pancreas — acute  pancreatitis,  arteriosclerosis, 
cysts,  and  cancer. 

Symptoms. — Sudden  severe  pain  in  the  epigastrium, 
vomiting,  tympanites,  dyspnea,  and  collapse  are  the  chief 
symptoms.  The  diagnosis  can  rarely  be  made  with  certainty. 

Prognosis. — Most  cases  prove  fatal  within  twenty-four 
or  thirty-six  hours,  death  being  due  to  an  arrest  of  the 
heart  from  injury  to  the  celiac  plexus  (Zenker)  or  semilunar 
ganglion  (Friedreich).     Pancreatitis,  cyst  of  the  pancreas. 


ACUTE  PANCREATITIS.  89 

and  peritonitis  are  possible  terminations.     Complete  recov- 
ery is  rare. 

Treatment.  —  Morphin  is  required  for  the  pain,  and 
stimulants  for  the  collapse.  If  the  patient  survives  the 
initial  collapse  and  symptoms  of  suppuration  develop, 
operation  is  indicated. 

ACUTE  PANCREATITIS, 

Varieties. — Hemorrhagic,  suppurative,  and  gangrenous. 

!^tiolo§y. — (i)  This  may  result  from  gall-stone  impac- 
tion, bile  being  retrojected  into  the  pancreatic  duct;  (2) 
from  inflammatory  affections  in  neighboring  parts — gastro- 
duodenal  catarrh,  gastric  ulcer,  or  cancer ;  (3)  from  general 
infections — specific  fevers  and  pyemia ;  (4)  from  traumatism. 
The  immediate  cause  is  bacterial  infection. 

Pathology. — In  the  hemorrhagic  form  the  organ  is 
irregularly  enlarged  and  the  seat  of  hemorrhagic  extrava- 
sation. Opaque,  white  spots  of  a  tallowy  consistence  are 
frequently  found  in  the  interlobular  tissue,  omentum,  and 
surrounding  parts,  and  represent  areas  oi  fat  necrosis. 

In  suppurative  pancreatitis  there  may  be  multiple  abscesses 
or  one  large  collection  of  pus.  More  or  less  extensive 
areas  of  necrosis  are  found.  Thrombosis  of  the  portal  and 
splenic  veins  is  frequently  encountered.  Pancreatic  abscesses 
may  become  encapsulated  or  they  may  rupture  into  the 
peritoneum,  stomach,  or  duodenum. 

Gangrenous  pancreatitis  is  usually  secondary  to  one  of  the 
other  varieties. 

Symptoms. — The  chief  symptoms  are  sudden  intense 
pain  in  the  epigastrium,  distention  of  the  epigastrium,  vom- 
iting and  collapse,  followed  in  suppurative  cases  by  irregu- 
lar fever,  constipation,  slight  jaundice,  delirium,  and  rapid 
loss  of  weight. 

Diagnosis. — Intestinal  Obstruction. — In  this  condition 
the  onset  is  usually  less  severe,  fecal  vemiting  is  common, 
pain  and  distention  are  less  frequently  limited  to  the  epigas- 
trium, and  constipation  is  absolute,  not  even  flatus  beingpassed. 

The  history  will  sometimes  serve  to  differentiate  the  con- 


90  DISEASES   OF   THE  DIGESTIVE   SYSTEM. 

dition  from  biliary  colic,  perforating  gastric  ulcer,  and  the 
effects  of  an  irritant  poison. 

Prognosis.  — Very  unfavorable.  The  duration  varies 
from  a  day  or  two  in  the  hemorrhagic  form,  to  several 
weeks  in  the  chronic  suppurative  variety.  Recovery  may 
follow  operation  or  rupture  of  the  abscess  into  the  bowel. 
It  may  rarely  end  in  chronic  pancreatitis. 

Treatment. — Operation  after  the  initial  collapse  offers 
some  hope  of  cure. 

CHRONIC  PANCREATITIS* 

(Cirrhosis  of  the  Pancreas.) 

etiology. — It  may  result — (i)  From  closure  of  the  pan- 
creatic duct  by  gall-stones  impacted  in  the  common  bile- 
duct  ;  (2)  from  extension  of  inflammation  in  gastroduodenal 
catarrh   or  pyloric  ulcer;  (3)  from  syphilis  or  alcoholism; 

(4)  from   sclerosis  of  the  pancreatic  arteries,  and,  possibly, 

(5)  from  acute  pancreatitis. 

Patholog"y. — The  chief  lesions  are  an  overgrowth  of  the 
fibrous  tissue  and  more  or  less  degeneration  or  atrophy  of 
the  cellular  elements. 

Synrptoms. — The  symptoms  are  obscure.  Flatulent 
dyspepsia,  paroxysmal  epigastric  pain,  a  tendency  to  diar- 
rhea, and  slight  jaundice  are  the  usual  features.  Albu- 
minuria and  glycosuria  may  occur.  Fatty  stools  have  been 
noted  in  a  few  instances.  When  the  islands  of  Lans^erhans 
are  involved  in  the  degenerative  process,  the  symptoms  of 
diabetes  mellitus  develop. 

Prognosis. — The  disease  runs  a  slow  course.  If  glyco- 
suria develops,  the  outlook  is  more  grave. 

Treatment. — The  use  of  fats  and  starches  should  be 
restricted.  Carbonated  waters  are  said  to  increase  pan- 
creatic secretion.  Pancreatin  is  recommended.  Surgical 
treatment  offers  a  good  chance  of  recovery  in  gall-stone 
cases. 

CANCER  OF  THE  PANCREAS* 

etiology. — The  disease  most  frequently  occurs  in  males 
past  forty  years  of  age. 


CYSTS   OF  THE   PANCREAS.  9 1 

Pathology. — Pancreatic  cancer  is  usually  primary;  it 
generally  involves  the  head  of  the  gland,  and  is  commonly 
of  the  scirrhous  variety. 

Symptoms. — These  include  disturbances  of  digestion, 
rapid  loss  of  flesh  and  strength,  anemia,  intense  deep-seated 
epigastric  pain,  and  the  presence  of  a  tumor.  The  latter  is 
usually  found  a  little  above  the  navel;  it  is  but  sHghtly 
movable,  deep  seated,  and  often  pulsatile  from  its  relation  to 
the  aorta.  The  pain  often  occurs  in  paroxysms,  especially 
at  night,  and  may  be  associated  with  the  symptoms  of  col- 
lapse. Progressively  increasing  jaundice,  with  enlargement 
of  the  gall-bladder,  is  a  frequent  symptom,  and  results  from 
the  pressure  of  the  tumor  upon  the  common  bile-duct. 
Pressure  on  the  portal  vein  may  cause  ascites.  Glycosuria 
is  an  occasional  symptom.  The  stools  rarely  contain  free 
fat,  but  the  presence  of  abundant  undigested  muscular  fibers 
in  the  dejections  in  the  absence  of  diarrhea  is,  according  to 
Fitz,  highly  suggestive. 

Diagnosis. — Gastric  cancer.  In  this  condition  the 
tumor  is  more  freely  movable,  is  usually  associated  with 
dilatation  of  the  stomach  and  with  marked  gastric  symptoms. 
Pain  is  not  usually  so  severe.     Jaundice  is  rare. 

CYSTS  OF  THE  PANCREAS- 

Varieties. — (i)  Retention  cysts  from  impaction  of  a  cal- 
culus, stricture,  or  tumor ;  (2)  apoplectic  cysts  from  hemor- 
rhagic extravasation  ;  (3)  hydatid  cysts  ;  (4)  congenital  cysts  ; 
(5)  proliferation  cysts  (carcinomatous  or  adenomatous). 

Pathology. — Pancreatic  cysts  may  be  single  or  multiple. 
They  lie  behind  the  stomach,  and  may  contain  from  a  few 
ounces  to  several  gallons  of  a  grayish  or  brownish,  viscid 
fluid,  of  an  alkaline  reaction,  of  a  specific  gravity  between 
1 010  and  1024,  and  presenting  the  characteristics  of  pancre- 
atic secretion. 

Symptoms. — These  are  very  variable,  the  most  common 
being  epigastric  pain,  vomiting,  constipation,  or  diarrhea, 
disturbances  of  digestion,  loss  of  flesh,  and  occasionally  in- 
testinal hemorrhage.      Free  fat  and  much  undigested  mus- 


92  DISEASES   OF  THE  DIGESTIVE  SYSTEM. 

cular  fiber  may  be  found  in  the  stools  and  sugar  in  the 
urine.  Physical  examination  often  reveals  in  the  upper  part 
of  the  abdomen  a  smooth,  elastic,  fluctuating  tumor  which 
on  aspiration  yields  a  fluid  capable  of  emulsifying  fats,  of 
converting  starch  into  sugar,  and  of  digesting  albumin. 
.  Prognosis  and  Treatment. — The  prognosis  is  guard- 
edly favorable  under  operative  treatment. 

PANCREATIC  CALCULL 

Pancreatic  calculi  are  probably  due  to  altered  glandular 
secretion  or  infection.  Their  passage  through  the  duct 
excites  pancreatic  colic,  the  symptoms  of  which  resemble 
biliary  colic,  but  the  pain  is  more  apt  to  radiate  to  the  left 
and  is  unattended  with  jaundice.  The  coexistence  of  glyco- 
suria with  fatty  stools,  and  the  discovery  in  the  stools  of 
concretions  containing  chiefly  carbonate  or  phosphate  of 
lime,  would  confirm  the  diagnosis. 


DISEASES   OF  THE   LIVER. 

The  liver  is  situated  in  the  right  hypochondrium,  with  a 
small  part  projecting  through  the  epigastrium  to  the  left 
hypochondrium. 

Area  of  Liver  Dulness. — The  absolute  dulness  (part  un- 
covered by  lung)  extends  in  the  mammary  line  from  the 
upper  border  of  the  sixth  rib  to  the  costal  margin ;  in  the 
axillary  line,  from  the  seventh  rib  to  the  eleventh  rib ;  in 
the  scapular  line,  from  the  ninth  rib  to  the  eleventh  rib ;  in 
the  median  line,  the  upper  border  is  lost  in  the  cardiac  dul- 
ness, while  the  lower  border  lies  midway  between  the  ensi- 
form  cartilage  and  the  umbilicus.  Slight  dulness  in  the 
mammary  line  begins  at  the  fifth  rib. 

Palpation. — Palpation  of  the  liver  is  practised  to  determine 
position,  size,  form,  and  consistence  and  to  detect  any  ten- 
derness or  pulsation. 

Conditions  in  which  the  liver  is  palpable : 

I.  In  thin  subjects  the  edge  is  sometimes  palpable  under 
normal  conditions. 


DISEASES   OF   THE   LIVER.  93 

2.  In  very  young  children  in  whom  the  liver  is  always 
proportionately  large. 

3.  In  depression  of  the  liver,  as  by  a  pleural  effusion  or 
by  a  consolidated  lung. 

4.  When  the  suspensory  ligaments  are  relaxed  and  the 
liver  "  wanders." 

5.  In  enlargement  of  the  organ  from  any  cause. 

6.  In  certain  abnormalities  of  form,  as  in  the  "  corset 
liver." 

Superficial  Irregularities. — Small  irregularities  may  be 
noted  in  cancer  of  the  liver,  syphilis  of  the  liver,  and  very 
rarely  in  atrophic  cirrhosis. 

Large  prominences  are  sometimes  noted  in  tumors,  ab- 
scesses, and  hydatid  cysts. 

Consistence, — The  liver  is  firm  to  the  touch  in  hypertro- 
phic cirrhosis,  cancer,  congestion,  leukemic  infiltration,  and 
amyloid  disease.  In  abscess  and  hydatid  disease  the  resist- 
ance is  less  marked  and  sometimes  fluctuation  can  be  noted. 

Tejiderfiess. — The  liver  is  tender  in  congestion,  abscess, 
cancer,  hypertrophic  cirrhosis,  and  in  affections  complicated 
with  perihepatitis. 

Pulsation  may  be  detected  in  the  venous  congestion  result- 
ing from  tricuspid  regurgitation,  in  abdominal  aneurysm, 
and  in  tumors  of  the  left  lobe  resting  on  the  aorta. 

Percussion. — Percussion  determines  size  and  resistance. 

The  liver  is  2iniformly  enlarged  in  :  (i)  Congestion,  active 
and  passive.  (2)  Fatty  infiltration.  (3)  Amyloid  infiltration. 
(4)  Hypertrophic  cirrhosis.  (5)  Leukemic  infiltration. 
(6)   Infiltrating    carcinoma. 

Irregular  enlargements  of  the  liver  are  noted  in  :  (i)  Can- 
cer.    (2)  Abscess.     (3)  Hydatid  disease.     (4)  Syphilis. 

The  liver  is  diminished  in  size  in  :  (i)  Atrophic  cirrhosis, 
late  stage.  (2)  Fatty  degeneration.  (3)  Acute  yellow 
atrophy.  (4)  Senile  atrophy.  The  area  of  hepatic  dulness 
may  be  diminished  from  certain  extrinsic  causes,  namely, 
pulmonary  emph^^sema,  excessive  tympanites,  and  perfora- 
tion of  the  stomach  or  bowel. 


94  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

JAUNDICE  OR  ICTERUS- 

Definition. — Pigmentation  of  the  tissues  and  secretions 
with  bile-pigments. 

Varieties. — (i)  Obstructive  jaundice.  (2)  Toxemic  jaun- 
dice. 

lEtiology  of  Obstructive  Jaundice. — Obstruction  to 
the  outflow  of  bile  leads  to  its  accumulation  and  reabsorp- 
tion. 

Obstruction  may  be  due  to  the  following  causes : 

1.  Stricture  of  the  bile-duct,  congenital  or  acquired. 

2.  Catarrh  of  the  bile-ducts  or  of  the  duodenal  mucous 
membrane  around  the  orifice  of  the  ductus  choledochus. 

3.  Foreign  bodies  in  the  ducts,  as  gall-stones  or  parasites. 

4.  Tumors  of  the  liver  or  of  adjacent  viscera  compressing 
the  ducts.  Fecal  accumulations,  a  pregnant  uterus,  and  dis- 
placed organs  may  similarly  compress  the  ducts. 

5.  Spasm  of  the  bile-ducts.  This  has  been  advanced  as 
the  cause  of  the  jaundice  that  occasionally  follows  emo- 
tional excitement. 

Symptoms. — The  skin,  mucous  membranes,  and  secre- 
tions are  stained  yellow.  The  discoloration  is  usually  first 
noticed  in  the  conjunctivae.  The  stools  are  light,  the  urine 
is  dark,  and  in  bad  cases  resembles  porter.  The  pulse  is 
usually  slow,  and  the  temperature  slightly  subnormal.  There 
is  often  more  or  less  mental  depression,  and  in  chronic 
cases  delirium,  convulsions,  and  coma  occasionally  develop. 
Itching  of  the  skin  is  often  noted,  and  urticaria  is  a  com- 
mon complication.  In  grave  cases  subcutaneous  ecchy- 
moses  may  appear. 

Diagnosis. — Other  discolorations,  like  the  bronze  hue 
of  Addison's  disease  and  the  green  tint  of  chlorosis  may  re- 
semble jaundice,  but  in  these  cases  the  conjunctiva  remains 
white  and  the  urine  lacks  bile. 

Btiology  of  Toxemic  Jaundice. — This  form  of  jaun- 
dice may  result  from — (i)  Certain  poisons,  as  toluylendi- 
amin,  phosphorus,  anilin,  chloroform,  and  snake  venom.  (2) 
Certain  general  diseases  of  infective  or  toxic  origin,  as  septi- 


JAUNDICE    OR   ICTERUS.  95 

cemia,  acute  yellow  atrophy,  malaria,  relapsing  fever,  and 
pernicious  anemia. 

In  toxemic  jaundice  there  is  also  obstruction,  but  it  is 
situated  in  the  minute  bile-ducts  instead  of  in  the  large 
ones.  The  chief  cause  of  the  obstruction  is  probably  catar- 
rhal inflammation  (cholangitis),  excited  by  the  poisons  cir- 
culating in  the  blood,  although  extensive  destruction  of  the 
red  blood-cells,  which  leads  to  the  secretion  of  a  thick,  vis- 
cid bile,  rich  in  pigments  (polychromia),  may  be  a  con- 
tributing factor  in  some  cases. 

Symptoms. — These  are  much  the  same  as  in  obstruc- 
tive jaundice,  but  the  staining  of  the  skin  is  not  so  intense, 
the  stools  still  contain  bile,  and  the  constitutional  symptoms 
are  apt  to  be  more  severe. 

ICTERUS  NEONATORUM. 

Physiologic  ictenis  in  the  new-born  is  slight ;  according  to 
Quincke,  it  is  probably  due  to  the  passage  of  blood  rich  in 
bile-pigments  absorbed  from  the  bowel  directly  into  the 
vena  cava  byway  of  the  ductus  arantii,  which  remains  patent 
for  several  days  after  birth. 

Pathologic  ictenis  in  the  new-born  is  marked,  and  com- 
monly proves  fatal.  It  results  from  congenital  stricture  of 
the  common  bile-duct,  syphilis  of  the  liver,  or  septic  infec- 
tion through  the  umbilical  vein. 

CHOLEMIA. 
(Cholesteremia ;  Acholia;  Hepatargy.) 

The  term  cholemia  has  been  applied  to  a  group  of  symp- 
toms which  sometimes  arises  in  chronic  jaundice  and  in  dis- 
eases of  the  liver  characterized  by  extensive  destruction  of 
the  liver-cells,  such  as  acute  yellow  atrophy,  cirrhosis,  and 
cancer. 

The  symptoms  of  cholemia  include  delirium,  convul- 
sions, stupor,  and  coma.  Subcutaneous  ecchymoses  and 
hemorrhages  from  mucous  membranes  are  also  frequently 
observed. 


96  DISEASES   OF  THE  DIGESTIVE  SYSTEM. 

The  cause  of  this  condition  is  supposed  to  be  the  reten- 
tion in  the  blood  of  toxic  matters  which  the  hver  normally 
converts  or  eliminates. 


CATARRHAL  JAUNDICE. 

(Catarrhal  Hepatitis;  Catarrhal  Angiocholitis ;  Catarrh  of  the 

Bile-ducts.) 

l^tiologfy. — (i)  The  most  common  cause  is  the  exten- 
sion of  a  gastroduodenal  catarrh  into  the  ducts.  (2)  Pri- 
mary inflammation  of  the  ducts  may  result  from  exposure 
to  cold  and  wet.  (3)  It  may  be  induced  by  irritation  from 
gall-stones.  (4)  It  may  be  infectious,  complicating  malaria, 
pneumonia,  relapsing  fever,  and  similar  diseases. 

Pathology. — The  large  ducts  are  particularly  affected ; 
the  mucous  membrane  is  swollen  and  covered  with  tena- 
cious mucus.  When  the  gall-bladder  is  compressed,  bile  is 
ejected  through  the  duodenal  orifice  with  less  ease  than  is 
natural. 

Symptoms. — (i)  Symptoms  of  gastroduodenal  catarrh 
usually  precede.  These  are:  Coated  tongue,  anorexia,  fetid 
breath,  epigastric  distress,  vomiting,  and  perhaps  diarrhea. 
(2)  Obstructive  jaundice,  indicated  by  yellow  skin  and  con- 
junctivae, light  stools,  and  dark  urine,  is  a  constant  symp- 
tom. (3)  In  acute  cases  there  is  slight  fever  with  swelling 
and  tenderness  of  the  liver. 

Diagnosis. — This  is  based  upon  the  acute  course,  the 
mild  character  of  the  symptoms,  the  history  of  preceding 
gastric  catarrh,  and  the  youth  of  the  patient. 

Prognosis. — Favorable.  It  rarely  becomes  chronic. 
The  average  duration  of  the  disease  is  from  two  to  six 
weeks. 

Treatment. — The  diet  should  be  simple  and  digestible. 
Fatty  and  saccharine  food  should  be  avoided.  Milk,  broths, 
eggs,  lean  meats,  oysters,  and  well-cooked  cereals  are  ad- 
missible. Sodium  phosphate  (i  dram  three  times  a  day), 
silver  nitrate  (J  grain  three  times  a  day),  and  ammonium 
chlorid  (5  to  10  grains  three  times  a  day)  are  of  value  in  re- 
lieving the   primary  gastroduodenal  catarrh.     In  obstinate 


ACUTE   CHOLECYSTITIS.  97 

cases  nitrohydrochloric  acid  may  prove  beneficial.  Daily 
irrigation  of  the  colon  with  from  i  to  2  quarts  of  cold  water 
is  sometimes  of  service.  Free  water-drinking  between  meals 
is  to  be  recommended.  Alkaline  mineral  waters  (Vichy, 
Vals,  Hathorn)  often  act  well. 

Chronic  catarrhal  jaundice  may  follow  repeated  acute 
attacks;  in  the  large  majority  of  cases,  however,  it  is  a 
sequel  of  stenosis  of  the  common  bile-duct  from  gall-stones, 
stricture,  or  pressure  from  without.  A  constant  symptom 
is  chronic  jaundice.  In  some  cases  there  are  recurrent 
attacks  of  intermittent  fever  with  chills  and  sweating  (Char- 
cot's intermittent  hepatic  fever). 

ACUTE  CHOLECYSTITIS* 

Definition. — Acute  inflammation  of  the  gall-bladder. 

!^tiolog"y. — The  disease  is  always  infectious,  the  organ- 
isms most  commonly  present  being  the  colon  bacillus, 
typhoid  bacillus,  pneumococcus,  staphylococcus,  and  strepto- 
coccus. Injury  to  the  mucosa  by  gall-stones  is  an  important 
predisposing  factor.  It  is  not  an  uncommon  sequel  of 
typhoid  fever  and  pneumonia. 

Pathology. — The  inflammation  may  be  catarrhal  or 
suppurative.  Suppurative  cholecystitis  {empyema  of  the  gall- 
bladder) is  usually  associated  with  purulent  inflammation  of 
the  bile-ducts,  and,  unless  promptly  relieved  by  operation, 
proceeds  to  ulceration  or  gangrene  and   general  peritonitis. 

Symptoms. — In  catarrhal  cases  the  symptoms  are 
slight  fever,  pain  in  the  hepatic  region,  tenderness  and 
enlargemenj:  of  the  gall-bladder,  and,  occasionally,  jaundice. 
In  the  suppurative  form  there  are  severe  paroxysmal  pain, 
a  septic  type  of  fever,  leukocytosis,  enlargement  and  tender- 
ness of  the  gall-bladder,  and,  in  some  cases,  jaundice. 

Diagnosis. — It  must  be  distinguished  from  apperidicitis, 
stibphrenic  abscess,  diX\^  amte  pancreatitis.  The  discriminating 
features  are  the  history  of  previous  cholelithiasis,  typhoid 
fever,  or  pneumonia,  and  the  locality  of  the  pain,  tenderness, 
and  swelling. 

Prognosis. — Very  grave    in   suppurative  cases.      Early 
operation,  however,  offers  considerable  hope  of  success. 
7 


98  DISEASES   OF  THE   DIGESTIVE  SYSTEM. 

CHOLELITHIASIS, 

(Gall-stones;  Biliary  Calculi.) 

etiology. — Gall-stones  are  three  or  four  times  more 
common  in  women  than  in  men.  They  occur  most  fre- 
quently after  middle  life,  and  are  rarely  seen  before  twenty- 
five.  Sedentary  habits,  high  living,  tight  lacing,  obstruction 
of  the  ducts,  and  other  factors  that  favor  stagnation  and 
inspissation  of  the  bile  predispose  to  their  formation.  Their 
occurrence  after  typhoid  fever  and  other  infections  is  not 
uncommon.  The  direct  cause  appears  to  be  a  microbic 
infection  of  the  gall-bladder,  in  consequence  of  which  ex- 
cessive quantities  of  cholesterin  and  lime  are  excreted  by 
the  irritated  mucous  membrane  and  deposited  upon  des- 
quamated epithelium  or  clumps  of  bacteria. 

Pathology. — Gall-stones  may  be  found  in  the  ducts,  but 
in  the  large  majority  of  cases  they  originate  in  the  gall- 
bladder. There  may  be  one  or  several  hundred.  When 
multiple,  they  are  found  with  facets,  from  attrition.  The 
size  varies  from  that  of  a  grain  of  sand  to  that  of  a  large 
walnut.  The  color  varies  from  light  yellow  to  dark  green. 
The  chief  constituent  is  cholesterin,  but  bile-pigments  and 
lime-salts  also  enter  in  their  composition.  On  section,  they 
usually  present  a  concentric  arrangement. 

Events. — (i)  Gall-stones  often  remain  quiescent  in  the 
gall-bladder.  (2)  In  consequence  of  violent  expulsive 
efforts,  excited  by  irritation  of  the  gall-bladder,  they  may 
be  extruded  into  the  bowel,  intense  pain  {biliary  colic) 
marking  their  passage  through  the  ducts.  (3)  Instead  of 
making  a  complete  exit,  they  may  slip  back  into  the  gall- 
bladder or  they  may  become  impacted  in  the  cystic  duct, 
or,  more  often,  in  the  lower  part  of  the  common  duct.  (4) 
They  may  perforate  into  the  duodenum,  peritoneum,  lung, 
stomach,  or  kidney,  or  externally.  Perforation  may  be  fol- 
lowed by  stricture  of  the  ducts  or  by  fistulous  communica- 
tions between  the  ducts  and  the  gastro-intestinal  canal. 
Perforation  into  the  duodenum  is  not  a  rare  cause  of  intes- 
tinal obstruction.  (6)  Invasion  of  the  gall-bladder  with 
pathogenic   microbes  in  cases  of  cholelithiasis  is  not  infre- 


CHOLELITHIASIS.  99 

quently  followed  by  suppurative  cholecystitis,  suppurative 
angiocholitis,  and  abscess  of  the  liver.  (7)  The  prolonged 
irritation  by  calculi  may  ultimately  give  rise  to  carcinoma 
of  the  biliary  passages. 

Symptoms  of  Biliary  Colic. — (i)  The  attacks  begin 
abruptly  with  intense  pain  radiating  from  the  hypochondriac 
region  to  the  right  shoulder.  There  are  usually  tenderness 
and  rigidity  over  the  gall-bladder.  Chill  and  fever  (102°- 
103°  F.)  often  mark  the  onset.  The  symptoms  of  intense 
pain  are  obvious — anxious  face,  cold  sweat,  feeble  pulse, 
and  vomiting.  Jaundice  may  follow  from  obstruction,  but 
it  is  often  absent.  If  the  stone  escapes,  it  may  subsequently 
be  found  in  the  stools.  The  attack  may  last  from  a  few 
hours  to  several  days. 

Diagnosis. — Renal  Colic. — In  this  affection  the  pain 
radiates  from  the  lumbar  region  along  the  ureter  into  the 
bladder  and  genitals.  Frequent  micturition  is  a  common 
symptom.  There  is  no  jaundice.  Blood  or  the  stone  may 
be  found  in  the  urine. 

Intestinal  colic  produces  pain  that  radiates  around  the 
umbilicus.  There  are  flatulence  and  borborygmi.  Jaundice 
is  absent. 

Gastralgia. — Pain  is  over  the  whole  stomach,  does  not 
radiate  to  the  shoulder,  and  is  relieved  by  pressure.  There 
is  no  jaundice. 

Gastric  Ulcer. — Pain  is  closely  related  to  eating.  There 
are  localized  tenderness  in  the  epigastrium,  hyperacidity, 
and  frequently  hematemesis. 

Symptoms  of  Obstruction  of  the  Cystic  Duct. — 
Obstruction  of  the  cystic  duct  may  be  followed  by  chole- 
cystitis, by  atrophy  of  the  gall-bladder,  or  by  dropsy  of  the 
gall-bladder  {liy drops  vesicce  fellce).  In  the  last  condition 
the  gall-bladder  can  often  be  felt  as  a  pear-shaped,  elastic, 
movable  tumor,  projecting  from  the  lower  margin  of  the 
liver.  Jaundice  is  not  present,  and  subjective  symptoms 
are  slight. 

Symptoms  of  Obstruction  of  the  Common  Duct. — 
In  typical  cases  the  symptoms  are — (i)  Chronic  jaundice 
showing  marked  variations  in  intensity ;  (2)  pain,  also  sub- 


lOO  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

ject  to  distinct  exacerbations;  (3)  recurrent  attacks  of  in- 
termittent fever,  with  chills  and  sweats  (Charcot's  hepatic 
fever).  The  liver  is  not  enlarged ;  the  gall-bladder  is  not 
distended,  but  often  atrophied  from  antecedent  attacks  of 
cholecystitis.  This  condition  may  last  for  months  or  years. 
It  not  infrequently  leads  to  suppurative  angiocholitis,  to 
biliary  cirrhosis,  or  to  acute  or  chronic  pancreatitis. 

Diagnosis. — Obstruction  of  the  Common  Duct  from  With- 
out (Cancer). — The  jaundice  increases  steadily  and  is  without 
remission,  the  gall-bladder  is  enlarged,  and  characteristic 
colic  and  hepatic  fever  are  wanting. 

Prognosis. — In  the  absence  of  complications  the  prog- 
nosis of  cholelithiasis  is  good.  It  must  be  borne  in  mind, 
however,  that  grave  complications  (suppurative  cholecystitis 
or  angiocholitis,  perforation,  hemorrhagic  pancreatitis)  may 
arise  most  unexpectedly. 

Treatment. — Efforts  must  be  directed  to  keeping  the 
stones  quiescent  by  preventing  irritation  or  catarrh  of  the 
gall-bladder.  The  food  should  be  plain  and  readily  digest- 
ible. Saccharin  matters,  fat  meats,  and  highly  seasoned 
dishes  should  be  avoided.  Water-drinking  between  meals 
should  be  encouraged.  Regular  exercise  in  the  open  air, 
provided  the  symptoms  are  latent,  is  extremely  bene- 
ficial. 

Digestive  disturbances  should  receive  appropriate  treat- 
ment. AmoncT  druo-s,  alkalis  and  alkaline  mineral  waters 
are  undoubtedly  efficacious.  Sodium  bicarbonate  or  sodium 
phosphate  may  be  taken  well  diluted  in  the  morning  an 
hour  before  breakfast  and  also  between  meals.  If  there 
is  decided  constipation,  a  small  quantity  of  Rochelle  salt 
or  sodium  sulphate  may  be  added  to  each  potation.  The 
natural  mineral  waters,  notably  those  of  Carlsbad  and 
Vichy,  have  acquired  a  high  reputation.  When  there  is  a 
tendency  to  so-called  bilious  attacks,  an  occasional  course 
of  calomel  in  fractional  doses  will  be  found  of  benefit. 

Surgical  intervention  is  called  for  :  (i)  When,  despite 
medical  treatment,  attacks  of  coHc  occur  so  frequently  and 
are  of  such  severity  as  to  cause  disability  or  make  the 
addiction  to  morphin  a  likelihood  ;  (2)  in  persistent  obstruc- 


HYPEREMIA    OF  THE  LIVER,    .  lOI 

tion  of  the  common  duct ;  (3)  in  hydrops  of  the  gall-bladder 
due  to  impaction  or  stricture  of  the  cystic  duct ;  and  (4)  in 
suppurative  inflammation  of  the  gall-bladder  or  gall-ducts. 

Hepatic  Colic. — Morphin  (J  grain)  and  atropin  (y5~o  grain) 
should  be  given  hypodermically.  Agonizing  pain  often 
yields  very  promptly  to  a  few  whiffs  of  chloroform.  In  the 
mild  but  rather  persistent  attacks  a  few  doses  of  antipyrin 
in  hot  water  may  suffice.  The  external  application  of  heat 
(poultice  or  hot  bath)  is  very  useful. 

When  vomiting  is  urgent,  carbonated  water  or  champagne 
may  be  given.  In  threatened  collapse  diffusible  stimulants 
are  needed. 

Obstruction  of  the  Common  Duct. — The  measures  best  suited 
for  promoting  the  advance  of  the  stone  into  the  bowel  are 
rest,  regulation  of  diet,  the  free  use  of  alkaline  mineral 
waters,  the  occasional  exhibition  of  saline  laxatives,  and  the 
application  of  heat  to  the  hypochondriac  region.  Olive  oil 
has  been  recommended  as  a  special  remedy,  but  it  is  of 
doubtful  efficacy.  As  the  sequelae  of  impaction  of  the  com- 
mon duct  are  so  grave,  surgical  aid  should  be  invoked  if 
the  obstruction  is  not  removed  under  medical  treatment 
within  a  period  of  three  or  four  weeks. 

HYPEREMIA  OF  THE  LIVER. 

Varieties. — (i)  Active  hyperemia.  (2)  Passive  hyper- 
emia. 

Ktiology. — Active  hyperemia  is  commonly  due  to  dietetic 
indiscretions.  It  may  result  from  overindulgence  in  alcohol. 
It  is  often  present  in  the  infectious  fevers.  It  appears  to 
arise  idiopathically  in  hot  climates. 

Passive  hyperemia  results  from  diseases  that  obstruct  the 
venous  circulation,  as  chronic  heart  and  lung  disease. 

Pathology. — The  liver  is  enlarged  and  filled  with  blood. 
In  the  passive  variety,  the  center  of  the  lobule,  the  area  of 
the  hepatic  vein,  is  deeply  pigmented,  while  the  periphery, 
the  area  of  the  portal  vein,  is  pale.  This  mottled  appear- 
ance has  given  rise  to  the  term  "  nutmeg  Hver."  In  per- 
sistent cases  pigmentation,  atrophy  of  the  liver-cells,  and 


I02  DISEASES   OF  THE  DIGESTIVE  SYSTEM. 

overgrowth  of  the  connective  tissue  result^a  condition 
termed  "  cyanotic  induration." 

Symptoms. — Active  Hyperemia. — The  Hver  is  enlarged 
and  somewhat  tender.  There  is  a  sense  of  fuhiess  or  even 
actual  pain  in  the  hepatic  region.  There  may  be  slight  jaun- 
dice. Digestive  disturbances — anorexia,  nausea,  flatulence, 
headache,  and  epigastric  tenderness  usually  coexist. 

In  the  passive  va^Hety  the  symptoms  are  much  the  same, 
though  less  marked.  The  liver  is  often  quite  large,  and  in 
extreme  cases,  such  as  follow  tricuspid  regurgitation,  it  may 
pulsate. 

Prognosis. — In  simple  active  congestion  the  prognosis 
is  good.  In  passive  congestion  the  prognosis  depends  on 
the  cause. 

Treatment.^ — Active  hyperemia  from  dietetic  errors 
usually  yields  promptly  to  restriction  of  the  diet  and  the  ad- 
ministration of  a  mercurial  purge,  followed  by  a  saline — 
Rochelle  salt,  Seidlitz  powder,  or  sodium  phosphate.  In 
recurring  attacks,  in  addition  to  hygienic  and  dietetic  regu- 
lations, a  pill  like  the  following  often  proves  useful : 

R.    Massae  hydrargyri g^"-  v 

Pulveris  rhei 

Extract]  gentianse aa  ^ss 

Olei  caryophylli gtt.  iv. — M, 

Fiant  pilulae  No.  xx. 

SiG. — One  or  two  occasionally,  as  directed  ;  to  be  continued,  if 
required,  thrice  daily  for  several  days. 

In  passive  congestion  treatment  must  be  directed  to  the 
primary  disease.  In  mild  cases  alkaline  mineral  waters 
(Carlsbad,  Congress,  and  Friederichshall)  do  well.  A  mer- 
curial laxative  may  be  used  from  time  to  time.  In  severe 
cases  the  most  effective  measures  are  absolute  rest,  a  milk 
diet,  saline  purges,  and  wet-cupping  over  the  liver. 

CIRRHOSIS  OF  THE  LIVER* 

(Chronic  Interstitial  Hepatitis.) 

Definition. — A  chronic  disease  of  the  liver  character- 
ized by  a  hyperplasia  of  the  connective  tissue  and  more  or 
less  extensive  retrograde  changes  in  the  liver-cells. 


CIRRHOSIS   OF   THE   LIVER.  IO3 

Varieties. — The  most  important  varieties  are  atrophic 
cirrlwsis^  hypcrtropJiic  cirrhosis,  syphilitic  cirrhosis,  biliary  cir- 
rhosis, and  capsular  cii'rhosis. 

ATROPHIC   CIRRHOSIS. 
(Laennec's  Cirrhosis;  Alcoholic  Cirrhosis:  Gin-drinker's  Liver.) 

Ktiology. — It  occurs  most  commonly  in  males  of  middle 
age.  The  chief  cause  is  the  continued  use  of  alcohol,  espe- 
cially in  the  form  of  raw  spirits.  Syphilis  may  also  cause 
this  type  of  cirrhosis.  It  is  possible  that  some  cases  owe 
their  origin  to  the  specific  fevers. 

Pathology. — In  the  earliest  stages  the  liver  is  somewhat 
enlarged  from  hyperemia,  but  when  the  process  is  advanced 
the  organ  is  small,  hard,  and  covered  with  numerous  small 
nodules  or  granulations  ("  hob-nails  ").  A  section  of  the 
liver  reveals  a  network  of  fine  and  coarse  pearly  bands  of 
connective  tissue.  The  contraction  of  this  connective  tissue 
is  responsible  for  the  reduction  in  the  size  of  the  organ  and 
the  granular  surface. 

Microscopic  cxaini7iation  reveals  an  overgrowth  of  con- 
nective tissue  of  a  fibrous  or  cicatricial  character,  and  chiefly 
interlobular  in  distribution.  The  shrinking  of  this  tissue 
compresses  the  portal  veins  and  causes  degeneration  and 
atrophy  of  the  liver-cells. 

Symptoms. — Obstruction  of  the  portal  circulation  first 
causes  congestion  and  catarrh  of  the  stomach,  hence  the  initial 
symptoms  are  anorexia,  fetor  of  the  breath,  fulness  and  dis- 
tress after  eating,  eructations,  nausea,  vomiting  of  mucus, 
flatulence,  and  constipation.  For  months  and  even  years 
these  phenomena  may  be  the  only  evidence  of  the  disease. 
As  the  pressure  in  the  portal  system  increases,  the  collat- 
eral vessels  enlarge,  and  as  a  result  the  superficial  abdoininal 
veijts  become  prominent  and  Jiemorrhoids  develop.  Engorge- 
ment of  the  portal  system  also  leads  to  ascites  and  swelling 
of  the  feet,  to  enlargemcjit  of  the  spleen,  and,  not  infre- 
quently, to  copious  hemorrhage  from  the  stomach  or  bowel. 

At  first  the  liver  is  somewhat  enlarged ;  later,  however, 
the  area  of  percussion-dulness  is  distinctly  reduced.     There 


104  DISEASES   OF   THE  DIGESTIVE   SYSTEM. 

is  a  gradual  loss  of  flesh  and  strength.  The  skin  is  muddy- 
in  appearance,  but  conspicuous  jaundice  is  very  uncommon. 
Nervous  symptoms — dehrium,  stupor,  convulsions,  and 
coma — occasionally  appear  toward  the  end  of  the  disease. 
They  are  probably  due  to  the  retention  of  poisons  that  the 
liver  is  unable  to  convert  or  to  eliminate. 

The  majority  of  cases  terminate  fatally  in  from  three  to 
five  years,  or  in  from  one  to  two  years  after  the  compensa- 
tory circulation  fails.  Death  results  from  exhaustion,  hem- 
orrhage, pulmonary  edema,  intercurrent  disease,  or  toxemia. 

Complications. — The  kidneys,  heart,  and  blood-vessels 
are  often  coincidentally  involved  in  the  cirrhotic  process. 
Tuberculosis,  especially  of  the  peritoneum,  is  a  very  com- 
mon complication. 

Diagnosis. — In  the  early  stage  the  diagnosis  can  only 
be  suspected.  In  the  drunkard,  chronic  gastric  catarrh 
with  enlargement  of  the  liver  would  strongly  indicate  the 
disease. 

Thrombosis  of  the  portal  vein  produces  the  same  clinical 
picture,  but  the  symptoms  usually  develop  much  more 
rapidly. 

Chronic  Peritonitis  with  Effusion. — This  is  usually  tubercu- 
lous or  cancerous.  The  history,  abdominal  tenderness, 
the  detection  of  localized  masses  or  ill-defined  indurations, 
the  presence  of  other  foci  of  disease,  the  high  specific  gravity 
(above  1014)  of  the  ascitic  fluid,  and  the  absence  of  symp- 
toms indicating  portal  obstruction  will  generally  suggest 
chronic  peritonitis. 

Prognosis. — The  outlook  for  permanent  relief  is  bad. 

Treatment. — Alcohol  must  be  interdicted.  A  diet  of 
bland,  readily  digested  food  is  indicated.  The  gastric  ca- 
tarrh should  receive  appropriate  treatment.  Lavage  of  the 
stomach  is  contraindicated  on  account  of  the  presence  of 
esophageal  varicosities.  Potassium  iodid  is  of  service  in 
syphilitic  cases,  but  not  otherwise.  Ammonium  chlorid 
(10  grains  three  times  a  day)  is  sometimes  useful.  Portal 
congestion  is  best  relieved  by  the  administration  of  salines 
(sodium  phosphate  or  Rochelle  salt)  in  hot  water  one-half 
hour  before  breakfast. 


CIRRHOSIS   OF  THE   LIVER.  10^ 

Ascites  can  sometimes  be  removed  by  the  administration 
of  cathartics  and  diuretics.  A  concentrated  solution  of 
Epsom  salts  {^  to  i  ounce),  taken  in  the  morning  before 
breakfast,  is  usually  the  most  efficient  purgative.  Occasion- 
ally it  may  be  desirable  to  substitute  compound  jalap  pow- 
der or  elaterium.  The  diuretics  of  approved  value  are 
potassium  acetate  or  bitartrate,  digitalis,  and  squills. 

Niemeyer's  pill  has  a  well-deserved  reputation : 

^.     Massse  hydrargyri 

Pulveris  digitalis 

Pulveris  sciJlae, „    .    »    .  aa  gr.  xx. — M. 

Fiant  pilulse  No.  xx. 

SiG. — One  pill  thrice  daily. 

When   the  ascites    is   large  and  does   not  yield  readily  to 
drugs,  paracentesis  should  be  practised  (see  p.  Ii6). 

Surgical  Treatment. — Talma's  operation  (suture  of  the 
omentum  to  the  margin  of  the  abdominal  incision  and  irri- 
tation of  the  peritoneal  surfaces  of  the  liver)  or  one  of  its 
modifications,  has  proved  of  some  benefit  in  a  limited  num- 
ber of  cases  of  liver  cirrhosis  with  ascites.  The  object  of 
the  operation  is  to  establish  a  compensatory  circulation  by 
making  accidental  adhesions  and  thus  increasing  the  anas- 
tomoses between  the  vessels  of  the  portal  system  and  those 
of  the  systemic  circulation.  The  operation  is  contraindi- 
cated  when  cardiac  or  renal  disease  coexists. 

HYPERTROPHIC  CIRRHOSIS. 
(Hypertrophic  Cirrhosis  of  Hanot.) 

Pathology. — The  causes  of  hypertrophic  cirrhosis  are 
not  understood.  Alcohol  does  not  appear  to  be  a  factor. 
It  is  seen  chiefly  in  men  between  twenty  and  thirty  years  of 
age.  The  liver  is  greatly  enlarged  throughout  the  entire 
course  of  the  disease.  The  organ  is  of  yellowish  or  green- 
ish color,  and  its  surface  is  smooth  or  finely  granular. 

Microscopically,  a  proliferation  of  connective  tissue  is 
found,  but  the  latter  is  chiefly  intralohdar,  is  more  cellular 
than  fibrous,  and  shows  little  tendency  to  contract.  The 
liver-cells  remain  intact  and  not  infrequently  share  in  the 
prohferation. 


I06  DISEASES   OF   THE  DIGESTIVE   SYSTEM. 

Symptoms. — The  liver  is  much  enlarged  permanently, 
often  tender,  and  the  seat  of  recurrent  attacks  of  pain. 
Jaundice  of  a  mild  type  is  rarely  absent.  The  stools,  how- 
ever, retain  their  normal  color.  The  spleen  is  enlarged. 
Hemorrhages  into  the  skin  and  from  mucous  membranes 
are  not  uncommon.  Toward  the  end  of  the  disease,  symp- 
toms of  hepatic  intoxication  may  develop.  Ascites,  profuse 
hematemesis,  and  enlargement  of  the  superficial  abdominal 
veins  are  rarely  observed.  The  course  is  long — often  from 
five  to  ten  years. 

The  treatment  is  that  of  congestion  of  the  liver.  Calo- 
mel and  potassium  iodid  have  been  recommended. 

OTHER  FORMS  OF  CIRRHOSIS  OF  THE  LIVER. 

Syphilitic  Cirrhosis  of  the  Wver. — In  the  diffuse 
form  the  appearance  of  the  liver  is  similar  to  that  of  alco- 
holic cirrhosis.  In  the  gummatous  form,  however,  the 
organ  is  enlarged  and  often  coarsely  lobulated  from  fibrous 
transformation  of  the  gummata.  A  history  of  syphilitic  in- 
fection, an  enlargement  of  the  liver  that  is  grossly  nodular, 
and  a  fair  preservation  of  the  general  health  will  suggest  the 
condition.  The  disease  often  responds  favorably  to  anti- 
syphilitic  treatment. 

Biliary  Cirrhosis  of  the  I/iver. — This  form  is  due  to 
stasis  of  the  bile  and  results  from  persistent  obstruction  of 
the  bile-ducts  by  calcuH,  stricture,  or  tumor.  Clinically,  it 
resembles  the  hypertrophic  cirrhosis  of  Hanot,  but,  unlike 
the  latter,  the  jaundice  is  very  intense  and  develops  rapidly, 
the  stools  are  devoid  of  bile,  the  liver  is  only  moderately 
enlarged,  and  the  course  is  short — rarely  more  than  two  or 
three  years. 

Capsular  Cirrhosis  (Chronic  Perihepatitis). — This 
form  is  characterized  by  enormous  thickening  of  the  capsule 
of  the  liver.  The  symptoms  closely  resemble  those  of 
atrophic  cirrhosis,  but  the  course  is  extremely  slow,  the 
ascites  returning  again  and  again  after  tapping.  In  many 
cases  interstitial  nephritis,  chronic  capsulitis  of  the  spleen, 
chronic  peritonitis,  and  pericarditis  are  also  present. 


ABSCESS   OF   THE   LIVER.  lO/ 

ABSCESS  OF  THE  LIVER. 

(Acute  Suppurative  Hepatitis.) 

l^tiology. — Abscess  of  the  liver  is  probably  always  due 
to  the  action  of  micro-organisms — Amoeba  coli,  streptococ- 
cus, staphylococcus,  colon  bacillus.  They  may  enter  the 
liver  through  the  portal  vein,  hepatic  artery,  or  bile-ducts. 

(i)  Amebic  dysentery  is  a  very  common  cause,  the 
amebae  entering  the  liver  through  the  portal  vein.  Occasion- 
ally amebic  abscesses  occur  without  any  evidence  of  dysen- 
tery. (2)  Septic  emboli  from  gastric  ulcers,  duodenal 
ulcers,  purulent  appendicitis,  etc.,  may  also  lodge  in  the 
branches  of  the  portal  vein  and  thus  excite  a  suppurative 
inflammation  (suppurative  pylephlebitis).  (3)  Pyogenic 
organisms  may  enter  the  hepatic  artery  in  ulcerative  endo- 
carditis, abscess  of  the  lungs,  and  general  pyemia.  (4)  Sup- 
puration by  way  of  the  bile-ducts  sometimes  occurs  in 
angiocholitis  secondary  to  gall-stones.  (5)  Traumatism 
may  be  a  causal  factor.  (6)  Finally,  suppuration  may  result 
from  the  secondary  infection  of  an  echinococcus  cyst. 

Pathology. — The  abscesses  following  amebic  dysentery 
("  tropical  abscess  ")  and  traumatisms  are  generally  solitary, 
and  usually  occupy  the  right  lobe.  Metastatic  abscesses 
are  multiple. 

Events. — Hepatic  abscess  may  kill  by  septic  poisoning 
or  by  perforation  into  the  lung,  abdomen,  pleura,  pericar- 
dium, or  vena  cava.  Recovery  may  follow  operation  or 
spontaneous  rupture  into  the  bronchi,  into  the  stomach  or 
bowel,  or  externally. 

Symptoms. — Local  Symptoms. — The  liver  is  enlarged 
and  tender.  The  enlargement  is  more  often  upward  than 
downward.  Circumscribed  bulging  beneath  the  costal  arch 
is  sometimes  noted.  Fluctuation  is  occasionally  detected. 
There  is  usually  severe  pain  in  the  liver  region  and  right 
shoulder.  Exploratory  puncture  may  reveal  pus.  Slight 
jaundice  may  develop,  but  it  is  often  absent. 

Constitutional  Symptoms. — These  result  from  sepsis,  and 
include  fever  of  a  remittent  or  irregular  type,  chills,  profuse 
sweating,  marked  anemia,,  and  leukocytosis. 


I08  DISEASES   OF  THE  DIGESTIVE  SYSTEM. 

Rupture  into  the  lung  is  characterised  by  severe  cough, 
weak  breathing  at  the  base  of  the  right  lung,  and  the 
expectoration  of  brownish  matter,  sometimes  containing 
amebae. 

Diagnosis. — Hydatid  cysts  develop  slowly,  are  not  pain- 
ful, are  not  associated  with  septic  phenomena,  and  yield 
clear  fluid  on  aspiration. 

Cancer  of  the  Liver. — The  history,  marked  cachexia,  in- 
volvement of  other  organs,  presence  of  jaundice,  detection  of 
hard  nodules  on  the  surface  of  the  liver,  and  the  absence  of 
septic  phenomena  will  suggest  cancer. 

Intermittent  Fever  due  to  Impacted  Gall-stones. — In  this 
condition  the  pain,  fever,  and  sweating  are  often  periodic ; 
the  health  in  the  intervals  may  be  well  preserved ;  the  jaun- 
dice increases  at  each  paroxysm ;  the  symptoms  may  persist 
for  several  years. 

Prognosis. — Embohc  abscesses  are  invariably  fatal. 
Traumatic  and  amebic  abscesses  may  terminate  favorably 
upon  spontaneous  or  induced  evacuation. 

Treatment. — In  multiple  abscesses  treatment  is  pallia- 
tive. Large  solitary  abscesses  should  be  opened  and 
drained. 

CANCER  OF  THE  LIVER. 

Ktiolog"y. — Cancer  of  the  liver  is  more  common  in  men 
than  in  women.  It  is  infrequent  before  the  age  of  forty. 
Heredity,  traumatism,  and  chronic  irritation  from  gall-stones 
are  predisposing  factors. 

Pathology. — Primary  cancer  of  the  liver  is  rare ;  sec- 
ondary cancer  is  common.  The  primary  form  may  appear 
as  a  single  large  nodule  {massive  cancer)  or  as  a  wide-spread 
infiltrating  growth  (^nodular  cancer).  The  latter  form  is 
sometimes  associated  with  cirrhosis  of  the  liver  {cirrhotic 
cancer).  The  secondary  variety  is  usually  due  to  the  lodg- 
ment in  the  portal  capillaries  of  cancerous  emboli  derived 
from  a  primary  growth  in  one  of  the  neighboring  organs, 
especially  the  stomach.  The  liver  is  much  enlarged,  and 
studded  with  numerous  grayish-white  nodes,  some  of  which 


CANCER    OF   THE   LIVER.  IO9 

project  from  the  surface.  The  superficial  nodes  are  often 
depressed  at  the  center. 

Symptoms. — (i)  The  liver  is  enlarged  and  very  painful, 
and  often  presents  one  or  more  smooth,  hard  nodules. 
The  latter  may  show  a  central  depression.  (2)  Cachexia 
is  pronounced  and  develops  rapidly.  (3)  Jaundice  is  com- 
mon, but  it  is  rarely  intense.  (4)  Digestive  disturbances 
are  a  prominent  feature,  and  often  precede  the  hepatic  symp- 
toms. Ascites  sometimes  results  from  portal  obstruction. 
Toward  the  end,  slight  fever,  delirium,  stupor,  and  coma 
may  develop  (hepatic  intoxication). 

Diagnosis. — Hypertrophic  cirrhosis  may  be  distinguished 
by  the  smooth,  uniform  enlargement  of  the  liver,  the  en- 
largement of  the  spleen,  the  persistence  of  icterus  without 
loss  of  color  in  the  stools,  the  absence  of  marked  cachexia, 
the  age  of  the  patient  (between  twenty  and  forty),  and  the 
slow  course. 

Abscess. — This  may  be  distinguished  by  the  history,  the 
septic  fever,  and  the  results  of  exploratory  puncture. 

Syphilis  of  the  Liver. — The  history  of  specific  disease,  the 
age,  and  the  absence  of  cachexia  will  aid  in  the  diagnosis. 

Prognosis  and  Treatment. — Absolutely  unfavorable. 
The  duration  is  from  a  few  months  to  a  year.  Treatment 
can  only  be  palliative. 


HYDATID  CYST   OF  THE    LIVER. 

(Echinococcus  of  the  Liver.) 

!Etiology  and  Pathology. — Hydatid  cysts  are  formed 
by  the  embryos  of  the  Taenia  echinococcus,  a  small  tape- 
worm inhabiting  the  intestines  of  the  dog.  The  disease  is 
common  in  Iceland,  Australia,  and  some  parts  of  Europe, 
but  is  rare  in  America. 

The  eggs  of  the  worm  are  accidentally  ingested  by  man, 
and  embryos  are  liberated  in  the  stomach,  whence  they  may 
migrate  to  any  organ  ;  the  liver,  however,  is  most  commonly 
affected  through  the  portal  vein.  The  fixed  embryo  soon 
develops  into  a  cyst  that  is  composed  of  an  external  lami- 


no  DISEASES   OF   THE  DIGESTIVE   SYSTEM. 

nated  layer  and  an  internal  breeding  layer.  A  connective- 
tissue  layer  is  formed  on  the  outside  from  irritation. 

The  cyst  contains  a  clear,  non-albuminous  fluid  that  has  a 
specific  gravity  of  1005  to  1007,  and  which  is  rich  in  chlorids. 

Scolices  or  larvae  develop  from  the  breeding  layer ;  they 
are  provided  with  four  suckers  and  a  circle  of  hooklets,  and 
produce  daughter-cysts  within  the  parent-cyst.  When  in- 
gested by  the  dog,  the  larvae  develop  into  mature  tape- 
worms. 

Symptoms. — Small  cysts  excite  no  symptoms.  Large 
cysts  produce  an  irregular  enlargement  of  the  liver,  with  a 
sense  of  weight  or  fulness  in  the  hypochondriac  region.  If 
the  cyst  is  superficial,  an  elastic,  fluctuating  tumor  may  be 
detected  on  palpation.  On  percussion  a  peculiar  vibratory 
sensation  (hydatid  thrill)  may  be  imparted  to  the  hand. 
Aspiration  yields  a  clear  fluid  containing  the  characteristic 
hooklets.     Fever,  pain,  and  jaundice  are  usually  absent. 

!^veiits.— (i)  The  cyst  may  reach  a  certain  size  and 
then  become  quiescent.  (2)  Trifling  injury  may  convert  it 
into  abscess.  (3)  Rupture  of  the  cyst  into  neighboring 
organs  may  terminate  in  death  or  in  recovery. 

Diagnosis. — The  diagnostic  features  are  a  smooth, 
tense,  elastic  tumor  of  the  liver,  of  slow  growth,  without 
pain,  fever,  or  pronounced  disturbance  of  the  general  health, 
and  yielding,  upon  exploratory  puncture,  a  clear  fluid  con- 
taining hooklets. 

Prognosis. — In  uncomplicated  cases  the  prognosis  is 
guardedly  favorable. 

Treatment. — Aspiration  under  antiseptic  precautions  is 
sometimes  followed  by  permanent  recovery.  Surgeons  of 
the  largest  experience,  however,  prefer  free  incision  and 
evacuation  of  the  cysts.  Purulent  cysts  should  be  treated 
as  abscesses. 

AMYLOID  LIVER. 

(Waxy  Liver;  Lardaceous  Liver.) 

Definition. — An  enlargement  of  the  liver  due  to  the 
deposition  of  a  peculiar  albuminoid  substance. 


ACUTE    YELLOW  ATROPHY  OF   THE  LIVER.         Ill 

Ktiology. — The  chief  causes  are  prolonged  suppuration, 
especially  of  bones  ;  tuberculosis  ;  syphilis  ;  and  long-stand- 
ing cachexia. 

Pathology. — The  liver  is  uniformly  enlarged,  hard,  and 
smooth.  The  margins  are  blunt.  On  section,  the  surface 
presents  a  translucent,  wax-like  appearance,  and  is  colored 
mahogany  brown  with  Lugol's  solution.  The  degenerative 
process  begins  in  the  walls  of  the  blood-vessels  and  spreads 
to  the  connective  tissue. 

Symptoms. — The  liver  is  uniformly  enlarged,  smooth, 
firm,  and  painless,  and  presents  a  rounded  edge.  The 
spleen  and  kidneys  almost  always  share  in  the  degenera- 
tion, and,  in  consequence,  the  spleen  is  enlarged  and  hard 
and  the  urine  contains  albumin  and  tube-casts.  Anemia 
and  emaciation  are  often  pronounced.  Jaundice  and  ascites 
are  uncommon. 

Diagnosis. — This  is  based  on  the  history,  the  uniform 
enlargement  of  the  liver,  the  absence  of  pain,  of  jaundice, 
and  of  ascites,  and  the  involvement  of  other  organs.  In 
leukemia  the  liver  and  spleen  are  often  uniformly  enlarged, 
but  an  examination  of  the  blood  will  prevent  an  error  in 
diagnosis. 

Prognosis  and  Treatment. — The  prognosis  depends 
somewhat  upon  the  curability  of  the  primary  disease.  The 
outlook,  however,  is  always  grave.  The  treatment  must  be 
directed  to  the  causal  disease. 

ACUTE  YELLOW  ATROPHY  OF  THE  LIVER. 

(Acute  Parenchymatous  Hepatitis;  Malignant  Jaundice.) 

Definition. — A  very  rare  and  grave  disease  characterized 
anatomically  by  a  rapid  destruction  of  the  liver  tissue,  and 
manifested  clinically  by  jaundice,  hemorrhages,  a  reduction 
in  the  size  of  the  liver,  and  marked  cerebral  phenomena. 

!^tiology. — The  disease  occurs  more  frequently  in 
women  than  in  men.  It  is  usually  seen  between  the  ages 
of  twenty  and  thirty.  Pregnancy  is  a  predisposing  factor. 
Alcoholic  excesses,  syphilis,  and  emotional  excitement  have 
been   given  as  exciting  causes.     The   rapid  course,  wide- 


112  DISEASES   OF  THE  DIGESTIVE   SYSTEM. 

spread  lesions,  and  the  fact  that  the  disease  has  occurred 
endemically  suggest  a  toxic  or  infectious  origin. 

Pathology. — The  liver  is  reduced  in  size,  flaccid,  and 
friable.  The  surface  is  yellowish  red  and  mottled.  Micro- 
scopic examination  reveals  advanced  necrosis  of  the  liver- 
cells,  hemorrhagic  extravasations,  hematogenous  pigmen- 
tation, and  occaasionlly  small-celled  infiltration.  The  other 
organs  are  usually  the  seat  of  fatty  and  parenchymatous 
degeneration. 

Symptoms. — (i)  The  initial  symptoms  are  those  of 
catarrhal  jaundice.  (2)  Nervous  symptoms  (cholemid)  soon 
follow  ,  these  are  severe  headache,  maniacal  dehrium,  stupor, 
and  coma.  (3)  The  urine  is  scanty,  and  usually  contains 
leucin  and  tyrosin,  bile,  albumin,  and  tube-casts.  The  ex- 
cretion of  urea  is  often  greatly  diminished.  (4)  The  area 
of  hepatic  percussion  dulness  rapidly  decreases.  (5^  Hemor- 
rhages from  the  mucous  membranes  and  into  the  skin  are 
common.  Fever  is  usually  absent.  The  disease  rarely 
lasts  longer  than  a  week  or  ten  days.  Recovery  is  ex- 
tremely rare. 

Diagnosis. — In  aaiie  pJiospJioi'us-poisojting  acute  gas- 
tritis precedes  the  jaundice,  the  vomitus  and  stools  may  be 
phosphorescent  or  have  the  odor  of  phosphorus,  the  liver  is 
generally  enlarged,  and  the  urine  contains  much  sarcolactic 
acid. 

In  hypertrophic  cirrhosis  the  liver  is  enlarged  and  often 
painful,  the  course  is  slow,  and  leucin  and  tyrosin  rarely 
appear  in  the  urine. 

Treatment. — This  must  be  symptomatic. 

ACUTE  PERITONITIS. 

Definition. — An  acute  inflammation  of  the  peritoneum. 
The  process  may  be  general  or  localized. 

[Etiology. — The  disease  is  probably  always  caused  by 
bacteria,  which  enter  the  peritoneum  from  the  neighboring- 
viscera,  especially  the  alimentary  canal,  from  the  Fallopian 
tubes,  from  external  wounds,  or  directly  from  the  blood. 
The  organisms  most  frequently  found  are  the  Streptococcus 


ACUTE  PERITONITIS.  II3 

pyogenes,  Staphylococcus  pyogenes,  Bacillus  coli,  pneumo- 
coccus.  Bacillus  pyocyaneus,  and  gonococcus. 

Peritonitis  may  follow — ( i )  Perforation  of  the  peritoneum 
by  an  external  wound,  by  rupture  of  a  gastric  or  intestinal 
ulcer,  by  rupture  of  a  suppurating  appendix,  gall-bladder, 
or  Fallopian  tube,  or  by  rupture  of  a  visceral  abscess ;  (2) 
extension  of  a  septic  process  in  adjacent  structures — stom- 
ach, bowel,  gall-bladder,  pancreas,  uterus ;  (3)  traumatism; 
{4)  o-ene?^a/  i7^ections^septicemm,  specific  fevers,  rheumatism, 
tuberculosis,  etc. 

Pathology. — The  serous  surfaces  first  become  red  and 
lusterless ;  later  a  serofibrinous,  fibrinous,  or  purulent  exu- 
date is  formed.  Putrid  and  hemorrhagic  exudates  are  some- 
times observed. 

Symptoms. — The  most  prominent  symptoms  are  intense 
abdominal  pain  and  tenderness.  The  breathing  is  shallow 
and  thoracic.  To  relax  the  abdominal  parietes,  the  patient 
lies  motionless  upon  his  back,  with  the  legs  and  thighs 
flexed.  The  features  are  pinched,  and  the  expression  is 
anxious.  The  abdomen  is  distended,  and  its  walls  are  rigid. 
Percussion  at  first  reveals  general  tympany,  but  later  there 
may  be  dulness  in  the  flanks  from  the  gravitation  of  the 
exudate.  The  temperature  is  usually  moderately  high 
(i02°-i04°  F.),  and  the  pulse  is  small,  rapid,  and  "  wnry." 
The  bowels  are  usually  constipated.  Vomiting  and  hiccup 
are  common  symptoms.  In  severe  cases  collapse  speedily 
ensues,  and  is  indicated  by  a  fall  in  the  temperature,  a  cold, 
clammy  surface,  a  rapid,  feeble  pulse,  and  suppression  of  urine. 

In  localized  peritonitis  the  constitutional  symptoms  are 
less  severe.  Pain,  tenderness,  and  rigidity  are  circum- 
scribed. General  tympanites  is  usually  absent.  Abscess 
formation  is  common. 

Diagnosis. — Acute  Enteritis. — In  this  disease  the  pain 
is  colicky  and  less  intense  ;  tenderness  is  much  less  marked  ; 
i  rigidity  is  rarely  present ;  there  is  diarrhea ;  the  constitu- 
tional symptoms  are  not  so  grave. 

Intestinal  Obstruction. — Constipation  is  absolute ;  vomiting 
is  stercoraceous ;  fever  and  abdominal  tenderness  are  less 
pronounced. 


114  DISEASES   OF   THE    DIGESTIVE   SYSTEM. 

Hysteric  Abdomen. — This  condition  may  resemble  perito- 
nitis in  all  particulars.  The  personal  history  must  be  care- 
fully considered.  Fever  is  not  usually  present,  the  pulse  is 
not  usually  rapid  and  wiry,  and  when  the  attention  is  dis- 
tracted, the  pain  may  disappear. 

Prognosis. — Diffuse  septic  peritonitis  is  almost  inva- 
riably fatal.  The  duration  is  usually  from  two  to  six  days. 
Life  is  occasionally  saved  in  perforative  peritonitis  by 
prompt  operation.  In  localized  peritonitis  the  outlook  is 
much  more  favorable. 

Treatment. — Early  operation  offers  the  only  hope  of 
saving  life  in  perforative  or  septic  cases.  Apart  from  lapa- 
rotomy, treatment  is,  for  the  most  part,  palliative.  When 
the  stomach  is  retentive,  small  quantities  of  milk  and  lime- 
water  or  of  broth  may  be  given  by  the  mouth.  Ice  may 
be  given  to  suck.  If  vomiting  be  persistent,  nutrient  enemas 
are  to  be  given.  Locally,  either  very  cold  or  very  hot  ap- 
plications may  afford  relief  Opium  is  useful  in  allaying 
pain,  controlling  vomiting,  and  diminishing  peristaltic  move- 
ments. Remarkably  large  doses  are  often  well  borne.  In 
non-perforative  cases  saline  purgatives  in  concentrated  solu- 
tion (i  to  2  drams  every  two  hours)  may  be  given  until  the 
bowels  move  freely.  These  salts,  while  not  increasing  peri- 
stalsis, attract  serum  from  the  turgid  blood-vessels  and  thus 
relieve  congestion. 

CHRONIC  DIFFUSE  PERITONITIS. 

etiology. — Chronic  peritonitis  may  be  a  sequel  of  acute 
peritonitis.  In  a  few  instances  it  has  seemed  to  have  resulted 
from  syphilis.  In  the  vast  majority  of  cases  it  is  tuberculous 
or  cancerous. 

Pathology. — The  intestines  are  matted  together  by 
bands  of  fibrous  lymph.  The  omentum  is  often  contracted 
and  greatly  thickened.  Effusion  is  usually  present,  but  it 
varies  considerably  in  amount ;  it  is  highly  albuminous,  and 
in  the  tuberculous  and  cancerous  varieties  it  may  be  bloody. 

Symptoms. — Fever  is  slight  and  may  be  absent.  Pain 
is  not  severe,  and  is  frequently  paroxysmal.  There  is 
usually  more  or  less  diffuse  tenderness.     Anemia  and  ema- 


ASCITES.  1 1 5 

ciation  are  often  pronounced.  The  abdomen  is  generally 
distended ;  often  irregularly,  from  sacculated  effusions,  in- 
flated intestinal  coils,  or  the  projecting  matted  omentum. 
Palpation  often  detects  a  friction  fremitus  and  resistant 
masses  or  nodules.  Percussion  yields  dulness,  varying  in 
extent  with  the  amount  of  effusion.  When  the  fluid  is  sac- 
culated, the  dulness  may  be  irregularly  distributed.  Fluctua- 
tion can  sometimes  be  elicited.  On  tapping,  the  fluid  is 
turbid,  rich  in  albumin,  and  of  high  specific  gravity  (about 
1015).  In  cancerous  and  tuberculous  cases  it  is  frequently 
bloody. 

Diagnosis. — The  diagnosis  between  tuberculous  and  can- 
cerous peritonitis  is  not  always  easy.  The  tuberculous  form 
usually  occurs  in  persons  under  forty,  gives  rise  to  less 
cachexia  than  the  cancerous  form,  and  is  frequently  asso- 
ciated with  tuberculous  foci  elsewhere,  especially  in  the 
lung,  pleura,  testis,  or  Fallopian  tube.  In  doubtful  cases 
the  tuberculin  test  may  be  employed  or  a  guinea-pig  may 
be  inoculated  with  the  exudate. 

Prognosis. — Cancerous  peritonitis  is  invariably  fatal. 
Tuberculous  peritonitis,  while  always  grave,  not  infrequently 
ends  in  recovery,  especially  in  children. 

Treatment. — In  the  tuberculous  form  the  general  treat- 
ment should  be  that  of  pulmonary  tuberculosis.  When  the 
effusion  is  large,  aspiration  will  be  required.  Surgical  treat- 
ment (free  incision  with  washing-out  of  the  abdominal  cav- 
ity with  normal  salt  solution)  should  be  advised  in  suitable 
cases. 

ASCITES* 

Definition. — A  collection  of  serous  fluid  in  the  peri- 
toneal cavity. 

!^tiology. — (i)  It  may  result  from  the  causes  of  general 
dropsy — heart  disease,  nephritis,  chronic  lung  disease,  and 
anemia.  (2)  It  may  be  due  to  obstruction  of  the  portal  cir- 
culation, from  cirrhosis  of  the  liver,  tumor,  or  thrombosis 
of  the  portal  vein.  (3)  It  occurs  in  chronic  peritonitis. 
(4)  It  is   often  caused  by  tumors   of  the  abdomen. 

Symptoms. — When  the  effusion  is  large,  a  sensation  of 


Il6  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

weight  in  the  abdomen,  dyspnea,  scanty  urination,  and  edema 
of  the  feet  may  result  from  pressure. 

Physical  Sig^ns. — Inspection. — The  abdomen  is  dis- 
tended; the  surface  is  smooth  and  shining;  the  base  of  the 
thorax  is  broadened ;  the  navel  is  more  or  less  obliterated ; 
the  superficial  veins  are  frequently  enlarged ;  and,  when  the 
patient  lies  in  the  dorsal  position,  the  flanks  bulge. 

Palpation  may  elicit  fluctuation,  and  in  the  flanks  a  sense 
of  resistance. 

Percussion  reveals  dulness  and  resistance  in  dependent 
parts,  with  superincumbent  tympany.  The  dulness  is 
moveable  and  is  detected  in  the  flanks  when  the  patient 
occupies  the  dorsal  position. 

Aspiration. — The  fluid  is  usually  clear,  straw-colored,  and 
albuminous.  The  specific  gravity  is  from  loio  to  1020. 
In  cancerous  and  tuberculous  peritonitis  the  fluid  is  some- 
times bloody.     Occasionally,  chylous  fluid  is  present. 

Diagnosis. — Tympanites. — This  yields  universal  hyper- 
resonance  on  percussion. 

Ovarian  Cysts. — The  enlargement  is  at  first  unilateral. 
As  the  intestines  are  pushed  aside,  the  dulness  is  anterior 
and  the  resonance  is  in  the  flanks.     Vaginal  examination 

o 

often  furnishes  important  data.  The  fluid  of  the  cyst  has  a 
higher  specific  gravity  (1025). 

Distention  of  the  Bladder. — The  history,  the  location  of 
the  dulness,  and  the  results  of  catheterization  will  render 
the  diagnosis  apparent. 

Treatment. — Treatment  should  be  directed  to  the 
original  cause.  Hydragogue  cathartics  and  diuretics  are 
sometimes  useful.  Concentrated  saline  solutions,  compound 
jalap  powder  (20  to  40  grains),  and  elaterium  (-|-  grain)  are 
the  most  useful  cathartics.  Infusion  of  digitalis  (3  to  4 
fluidrams),  citrated  caffein  (2  to  3  grains),  potassium  citrate 
or  acetate  (20  grains),  and  Niemeyer's  pill  (see  p.  105)  are 
the  most  reliable  diuretics. 

li .      Potassii  citratis ^^ss 

Infusi  digitalis f^'^j- — ■'^• 

SiG. — A  tablespoonfal  thrice  daily. 

When  the  effusion  is  large  and  causes  discomfort  or  great 


ASCITES.  117 

diminution  in  the  quantity  of  urine,  paracentesis  should  be 
performed. 

Paracentesis  Abdominis. — The  bladder  having  been  emp- 
tied, the  patient  is  placed  in  a  semirecumbent  position,  and 
a  spot  in  the  median  line  midway  between  the  umbilicus 
and  the  symphysis  pubis  is  anesthetized  by  means  of  a 
block  of  ice  sprinkled  with  salt.  A  stout  trocar  is  now 
introduced  with  a  quick  thrust  into  the  abdominal  cavity,  a 
rubber  tube  is  attached  to  the  cannula  for  the  purpose  of 
conveying  the  fluid  into  a  pail  placed  below  the  patient's 
bed,  and  the  trocar  is  then  withdrawn.  While  the  fluid  is 
escaping,  a  many-tailed  bandage  is  adjusted  to  the  abdomen 
and  gradually  tightened.  The  application  of  such  a  binder 
should  never  be  omitted.  It  gives  support  to  the  relaxed 
abdominal  walls,  and  tends  to  prevent  syncope  and  hemat- 
emesis.  When  the  fluid  ceases  to  flow,  the  cannula  is 
removed,  and  the  opening  sealed  with  an  antiseptic  pad  and 
a  few  strips  of  adhesive  plaster. 

In  tuberculosis,  peritonitis,  and  in  cirrhosis  of  the  liver 
with  recurrent  ascites  surgical  treatment  sometimes  proves 
successful. 


DISEASES  OF  THE  KIDNEYS. 


THE  URINE. 

Normal  urine  is  a  pale,  amber-colored  fluid,  of  acid  reac- 
tion, having  a  specific  gravity  of  1015  to  1025,  and  amount- 
ing in  quantity  to  about  50  ounces  (1500  c.c.)  in  twenty-four 
hours. 

Polyuria. — An  increased  flow  of  urine. 

Temporary  polyuria  may  result  from — (i)  Excessive  in- 
gestion of  fluids.  (2)  Administration  of  diuretics.  (3)  Sup- 
pression of  perspiration.  (4)  Crises  of  certain  febrile  diseases, 
and  certain  neurotic  manifestations,  such  as  neuralgia  and 
hysteria.  (5)  Absorption  of  serous  effusions  and  transuda- 
tions. (6)  Removal  of  some  temporary  obstruction  in  the 
urinary  passages. 

Permane?it  polyuria  may  result  from — (i)  Diabetes  melli- 
tus.  (2)  Diabetes  insipidus.  (3)  Chronic  interstitial  ne- 
phritis.    (4)  Amyloid  kidney. 

Diminution  of  the  amount  of  urine  or  suppres- 
sion of  urine  (anuria)  occurs — (i)  When  there  is  ex- 
cessive secretion  through  other  channels,  as  in  perspira- 
tion and  diarrhea ;  (2)  in  fever ;  (3)  in  severe  congestion 
of  the  kidneys ;  (4)  in  acute  nephritis  and  late  in  chronic 
parenchymatous  nephritis ;  (5)  in  collapse ;  (6)  in  certain 
nervous  conditions,  as  in  some  cases  of  hysteria ;  and  (7) 
from  mechanical  obstruction,  as  in  compression  of  the  ureters 
by  tumors  and  in  enlargement  of  the  prostate  gland. 

Urea. — Urea  is  the  final  product  of  the  decomposition  of 
proteids  in  the  body.  A  large  part  is  formed  in  the  liver. 
It  is  completely  soluble  in  urine,  but  the  nitrate  of  urea 
crystallizes  in  the  form  of  transparent  imbricated  plates 
when  nitric  acid  is  added  to  urine  that  has  been  partially 
evaporated. 

]18 


THE    URINE.  119 

The  amount  of  urea  excreted  varies  greatly  in  health. 
Normal  urine  contains  about  2  per  cent,  of  urea.  The 
average  daily  amount  excreted   is  from   300  to  600  grains. 

The  excretion  of  urea  is  increased — (i)  After  the  inges- 
tion of  much  albuminous  food  ;  (2)  after  exertion  ;  (3)  in 
febrile  and  acute  inflammatory  diseases ;  (4)  in  diabetes ; 
(5)  after  the  use  of  certain  drugs,  as  thyroid  extract,  caffein, 
and  salicyHc  acid. 

The  excretion  of  urea  is  diminished — (i)  In  nephritis; 
(2)  in  inanition  and  cachexia;  (3)  in  destructive  diseases  of 
the  liver — acute  yellow  atrophy,  cirrhosis. 

Fowler's  Hypochlorite  Test  for  Urea. — Add  to  i  volume  of 
the  urine  7  volumes  of  Labarraque's  solution  of  chlorinated 
soda.  Shake  the  jar  containing  the  mixture  occasionally, 
and  stand  it  aside  for  two  hours,  when  the  urea  will  have 
been  decomposed.  Now  take  the  specific  gravity  of  the 
quiescent  fluid. 

Ascertain  the  specific  gravity  of  the  mixture  of  urine  and 
Labarraque's  solution  before  decomposition.  To  do  this, 
multiply  the  specific  gravity  of  the  pure  Labarraque's  solu- 
tion by  7,  add  this  to  the  specific  gravity  of  the  pure  urine, 
and  divide-  by  8.  The  result  is  the  specific  gravity  of  the 
mixed  fluid.  From  this  subtract  the  specific  gravity  of  the 
quiescent  mixture  after  decomposition  of  the  urea,  multiply 
the  difference  by  yj^  and  the  result  is  the  percentage  of 
urea  (Tyson). 

lyithuria. — Uric  acid  or  urates  in  the  urine.  These  sub- 
stances appear  to  be  derived  from  the  nuclein  of  cellular 
nuclei.  When  they  are  in  excess,  the  urine  is  heavy,  dark 
in  color,  and  on  cooling  throws   down  a  brick-red  deposit. 

Microscopically,  uric  acid  appears  as  reddish-yellow 
rhombic  prisms  or  lozenge-shaped  crystals. 

Amorphous  urates  appear  as  fine,  dark,  and  opaque 
granules. 

Crystalline  urates  appear  as  needles,  dumb-bells,  or  as 
globular  masses  from  which  sharp  spines  project. 

Murexid  Test  for  Uric  Acid  and  its  Salts. — Evaporate  a 
little  urine  in  a  porcelain  dish,  add  a  drop  or  two  of  strong 
nitric  acid,  and  heat  again  to  dryness.    Cool,  and  add  a  drop 


120 


DISEASES   OF  THE  KIDNEYS. 


of  liquor  ammoniae,  and  the  beautiful  purple  color  of  murexid 
is  developed. 

Urates. — The  urates  are  present  in  small  quantity  in  nor- 
mal urine.  They  may  become  perceptible  or  transiently 
increased:  (i)  In  urine  exposed  to  a  cold  atmosphere.  (2) 
In  urine  made  scanty  by  free  perspiration  or  diarrhea.  (3) 
When  the  acidity  of  the  urine  is  temporarily  increased. 
(4)  After  excessive  indulgence  in  nitrogenous  food. 

The  urates  are  increased  pathologically  in  many  diseases 
which  directly  or  indirectly  interfere  with   tissue  or   food 


Fig.  3. — Uric  acid  and  uric  acid  salts. 


metabolism,  notably  in :  (i)  Gout;  (2)  fever;  (3)  leukemia; 
(4)  indigestion  ;  (5)  diseases  of  the  lungs — from  interference 
with  oxidation. 

I/eucinuria  and  Tyrosinuria. — Leucin  and  tyrosin  are 
found  in  the  urine  in  certain  specific  fevers,  and  especially  in 
fatty  degeneration  of  the  liver  resulting  either  from  phos- 
phorus-poisoning or  from  acute  yellow  atrophy. 

They  may  be  detected  by  evaporating  a  few  drops  of  the 
urine  on  a  glass  slide.  Leucin  appears  in  the  form  of  small, 
round,  ghstening  spheres,   resembling  fat-drops,  but,  unHke 


THE    URINE. 


121 


the  latter,  they  are  insoluble  in  ether.  Tyrosin  appears  in 
the  form  of  intersecting  tufts  of  fine  acicular  crystals. 

Phosphaturia. — Phosphates  occur  in  two  forms,  amor- 
phous and  crystaUine. 

Amorphous  earthy  phosphates  are  found  in  alkaline  urine, 


Fig.  4. — a,  Tyrosin  crystals  ;  b,  leucin  crystals. 

and  are  precipitated  by  adding  a  few  drops  of  Hquor  am- 
moniae  to  the  urine. 

Crystallized  phosphate  of  lime  appears  as  stellar  or  rod- 
shaped  crystals  which  are  soluble  in  acetic  acid. 


Fig.  5. — Triple  phosphate. 

The  ammoniomagnesium  phosphate,  or  triple  phosphate, 
appears  in  decomposing  urine  as  transparent,  coffin-shaped 
prisms.  They  may  resemble  crystals  of  oxalate  of  lime, 
but,  unHke  the  latter,  are  freely  soluble  in  acetic  acid. 


122  DISEASES   OF   THE   KIDNEYS. 

The  presence  of  phosphates  in  the  urine  is  no  indication 
of  excess,  for  when  normal  in  amount,  they  are  often  pre- 
cipitated in  urine  that  is  temporarily  alkahne.. 

The  detection  of  triple  phosphates  in  newly  voided  urine 
indicates  decomposition  in  the  bladder,  a  condition  resulting 
from  vesical  catarrh. 

Phosphaturia  results  from  many  causes — certain  nervous 
diseases,  nervous  dyspepsia,  rickets,  osteomalacia,  leukemia, 
and  gout.  Cases  of  polyuria  with  phosphaturia  have  been 
described  {diabetes  phosphaticus). 

Chlorids. — The  quantity  of  these  salts  is  increased :  (i)  After 
exertion.     (2)  During  the  absorption  of  serous  effusions. 


Fig.  6. — Oxalate  of  lime. 


The  quantity  is  decreased :  (i)  In  most  febrile  diseases. 
(2)  In  nephritis.  (3)  In  many  wasting  diseases.  (4)  Espe- 
cially in  pneumonia. 

Test. — We  may  thus  roughly  estimate  the  quantity.  Add 
a  few  drops  of  strong  nitric  acid  to  the  urine,  remove  any 
albumin  that  may  be  present,  and  then  add  to  the  clear 
urine  a  little  of  a  strong  solution  of  nitrate  of  silver.  The 
abundance  of  the  white  precipitate  will  indicate  the  quantity 
of  chlorids    present. 

Oxaluria. — Oxalate    of  lime   appears    in   the    urine   as 


THE    URINE.  123 

dumb-bell-shaped  crystals    or  as  minute,  highly  refracting 
octahedra. 

They  are  found  in  excess  :  (i)  After  eating  certain  fruits 
and  vegetables,  as  spinach,  rhubarb,  cauliflower,  and  pears  ; 
(2)  in  certain  nervous  diseases,  notably  hypochondriasis, 
melancholia,  and  neurasthenia  ;  (3)  in  diabetes  ;  (4)  various 
digestive  disturbances. 

Tube-casts. — These  are  cylinders  of  albuminoid  sub- 
stances formed  in  the  uriniferous  tubules.  They  are  often 
composed  in  part  of  epithelial  cells,  blood-cells,  or  the 
products  of  degenerated  cells.     They  appear  as  : 

Hyaline  Casts. — These  are  clear,  translucent  cylinders, 
often  so  pale  as  to  be  scarcely  visible.  They  occur  in  the 
urine  in  all  forms  of  nephritis,  in  congestion  of  the  kidneys, 
in  jaundice,  and  even  in  health.  They  are  frequently  the 
only  casts  present  in  chronic  interstitial  nephritis. 

Waxy  Casts. — These  resemble  hyaline  casts,  but  they 
appear  more  solid  and  rigid  and  are  more  or  less  yellow. 
They  occur  especially  in  chronic  parenchymatous  nephritis. 

Epithelial  Casts. — These  are  cylinders  of  epithelial  cells 
or  hyaline  casts  covered  with  epithelial  cells.  They  occur 
especially  in  acute  parenchymatous  nephritis. 

Gra7iular  Casts. — These  are  cylinders  covered  with  the 
debris  of  broken-down  epithelial  cells.  They  may  occur  in 
any  form  of  nephritis. 

Fatty  Casts. — These  are  casts  studded  with 'oil-drops  de- 
rived from  degenerated  epithelium.  They  occur  chiefly  in 
chronic  parenchymatous  nephritis. 

Blood  Casts. — These  are  cylindric  masses  of  red  blood- 
cells,  or,  more  commonly,  hyaline  casts  studded  with  red 
blood-cells.  They  occur  in  acute  and  chronic  hemorrhagic 
nephritis. 

Pus  a7td  Bacterial  Casts. — Casts  composed  respectively 
of  masses  of  pus-cells  and  of  bacteria  are  occasionally  met 
with  in  suppurative  nephritis. 

Cylindroids.—Th^sQ  formations  may  resemble  hyahne 
casts,  but  they  are  usually  much  longer  and  often  taper  off 
at  one  end  to  a  thread.  Moreover,  they  frequently  show 
constrictions  at    different  points.     Their  presence  is  not  a 


124  DISEASES   OF  THE  KIDNEYS. 

proof  of  nephritis.  They  often  occur  in  conditions  of  renal 
irritation. 

Urobilinuria. — Urobilin  is  probably  a  derivative  of  bili- 
rubin. When  present  in  excess,  the  urine  is  dark  brown. 
When  deposited  in  the  tissues,  it  causes  a  brownish  pig- 
mentation known  as  urobilin-icterus.  The  urobilin  in  the 
urine  may  be  pathologically  increased — (i)  In  diseases 
associated  with  destruction  of  red  blood-cells,  as  pernicious 
anemia  and  scurvy  ;  (2)  after  the  absorption  of  hemorrhagic 
effusions ;  (3)  in  acute  infectious  diseases ;  (4)  in  certain 
liver  diseases  (cancer,  cirrhosis,  catarrhal  jaundice),  provided 
the  entrance  of  bile  into  the  bowel  is  not  entirely  prevented. 

Hematoporphyrinuria. — Hematoporphyrin  is  a  prod- 
uct of  the  decomposition  of  hemoglobin.  It  is  hematin  de- 
prived of  its  iron.  Large  amounts  impart  to  the  urine  a 
dark-red  color.  It  is  found  in  the  urine  in  a  large  number 
of  diseases,  and  in  chronic  poisoning  by  sulphonal  and 
trional. 

Glycosuria. — Grape-sugar  in  the  urine. 

Causes. — Normal  urine  contains  a  trace,  but  this  is  not 
recognizable  by  the  ordinary  tests.  Decided  glycosuria  is 
seen — (i)  In  diabetes  mellitus  ;  (2)  after  the  digestion  of 
large  amounts  of  saccharine  matter  ;  (3)  in  poisoning  by 
certain  drugs,  such  as  phloridzin,  nitrites,  chloroform  ;  (4)  in 
pregnancy;  (5)  in  diseases  or  injuries  to  the  floor  of  the 
fourth  ventricle  ;  (6)  in  lesions  of  the  pancreas  involving  the 
islands  of  Langerhans ;  (7)  in  many  nervous  diseases  and 
acute  infections — epilepsy,  tetanus,  cholera,  pertussis,  etc. 

Qualitative  Tests  for  Glucose. — The  copper  tests  are  com- 
monly employed,  and  depend  on  the  power  which  glucose 
possesses  of  converting  blue  oxid  of  copper  into  the  orange- 
yellow  suboxid. 

Trommers  Test. — Add  to  the  suspected  urine  half  its 
volume  of  liquor  potassae,  and  if  any  precipitate  falls,  filter 
the  solution  ;  then  add  one  or  two  drops  of  a  weak  solution 
(i  :  30)  of  sulphate  of  copper,  and  heat  the  resulting  mix- 
ture. If  sugar  is  present,  a  dense  yellow  or  red  precipitate 
falls. 

Simple  decolorization  of  the  fluid  is  no  proof  of  sugar. 


THE    URINE.  125 

Fehling's  Test. — As  the  fluid  employed  in  this  test  spoils 
on  keeping,  it  should  be  freshly  prepared  when  required  by 
mixing  in  equal  proportions  the  following  solutions  : 

First  solution  :  Dissolve  34.64  grams  of  pure  cupric  sul- 
phate in  distilled  water,  and  dilute  up  to  500  c.c. 

Second  solution:  Dissolve  180  grams  of  pure  Rochelle 
salt  and  70  grams  of  caustic  soda  in  400  c.c.  of  distilled 
water,  and  heat  to  boiling  ;  on  cooling,  make  up  to  500  c.c. 
with  distilled  water. 

To  about  ten  minims  of  each  solution  in  a  test-tube  add 
about  a  fluidram  of  distilled  water,  and  boil  for  a  few 
seconds ;  if  the  solution  remains  clear,  add  the  suspected 
urine  drop  by  drop,  and  occasionally  heat  the  tube.  If 
sugar  is  abundant,  a  yellowish-red  deposit  will  be  produced. 
If  no  precipitate  falls,  continue  the  addition  of  the  urine 
until  an  equal  volume  has  been  added,  and  allow  to  cool ; 
then  if  no  precipitate  falls,  sugar  is  absent. 

Tlie  Phenylhydrazin  Test. — Put  in  a  test-tube  half  filled 
with  water  phenylhydrazin  (hydrochlorate)  2  grains  and 
sodium  acetate  3  grains.  Dissolve  by  heating.  Fill  the 
tube  with  suspected  urine,  and  stand  in  boiling  water  for 
twenty  minutes.  Then  place  in  cold  water.  On  cooling, 
yellow,  radiating  groups  of  needle-shaped  crystals  of  phenyl- 
glucosazon  fall,  which  may  be  detected  under  the  micro- 
scope. 

Bottger's  Test. — Add  to  a  couple  of  drams  of  suspected 
urine  which  is  free  from  albumin  an  equal  volume  of  liquor 
potassae  and  a  few  grains  of  subnitrate  of  bismuth,  and 
boil ;  if  sugar  is  present,  it  will  reduce  the  salt  of  bismuth  to 
black  metallic  bismuth.  Substances  containing  sulphur, 
like  albumin,  yield  a  similar  black  precipitate. 

The  Fermentation  Test. — Fill  a  four-ounce  bottle  three 
parts  full  of  urine,  and  add  a  fluidram  of  ordinary  yeast  or  a 
small  portion  of  compressed  yeast ;  lightly  cork,  and  subject 
to  a  temperature  of  70°  to  80°  F.  for  ten  or  twelve  hours. 
If  sugar  is  present,  fermentation  results  with  the  evolution 
of  carbon  dioxid,  and  the  specific  gravity  of  the  urine  falls. 

Quantitative  Tests. — Fermentation  test :  Employ  two  bot- 
tles of  urine,  and  to  the  one  add  the  yeast ;  at  the  end  of 


126  DISEASES   OF  THE   KIDNEYS, 

twenty-four  hours  take  the  specific  gravity  of  each  specimen. 
Every  degree  lost  in  the  fermented  urine  indicates  a  grain 
of  sugar  to  the  fluidounce. 

Fehling's  Test. — To  i  c.c.  of  Fehling's  solution  add  4  c.c. 
of  distilled  water,  and  boil ;  if  the  solution  still  remains  clear, 
add  jlg-  c.c.  of  the  urine  from  a  graduated  pipet,  and  gently 
heat.  Continue  the  addition  of  the  urine,  Httle  by  little, 
until  all  blue  color  has  disappeared.  If  i  c.c.  of  urine  has 
been  added,  it  will  have  contained  half  of  i  per  cent,  of  sugar. 
If  2  c.c.  are  used,  it  will  have  contained  \  per  cent.  If  but 
half  of  a  cubic  centimeter  is  used,  it  will  have  contained 
I  per  cent. 

If  the  specific  gravity  indicates  that  the  amount  of  sugar 
is  great,  dilute  the  urine  with  a  definite  amount  of  water, 
and  estimate  accordingly  (Tyson). 

Albuminuria. — Albumin  in  the  urine. 

Causes. — It  occurs — (i)  In  all  forms  of  nephritis;  (2)  in 
congestion  of  kidneys  from  diseases  of  the  heart,  lungs,  and 
liver ;  (3)  in  conditions  profoundly  affecting  the  blood,  as  per- 
nicious anemia,  leukemia,  purpura,  and  poisoning  by  many 
drugs  ;  (4)  in  acute  febrile  diseases  ;  (5)  often  in  pregnancy ; 
(6)  occasionally  in  certain  persons  in  health,  as  in  young 
adults  after  exertion,  or  a  diet  rich  in  proteids  (cyclic  albu- 
minuria), or  even  upon  changing  to  the  upright  position 
(orthostatic  albuminuria)  ;  (7)  when  the  urine  contains  pus 
or  blood  (accidental  albuminuria) ;  (8)  in  many  nervous  dis- 
eases, as  apoplexy,  cerebral  concussion,  tetanus,  epilepsy. 

Tests  for  Albumin. — Heller's  Test. — Pour  a  small  quantity 
of  colorless  nitric  acid  in  a  test-tube,  and  allow  an  equal 
quantity  of  filtered  urine  to  trickle  from  a  pipet  down  the 
side  of  the  tube  and  to  come  in  contact  with  the  acid.  If 
albumin  is  present,  a  sharply  defined  white  ring  is  formed  at 
the  line  of  junction. 

Turpentine,  copaiba,  and  other  oleoresins  eliminated  in 
the  urine  yield  similar  rings,  but  the  latter  are  redissolved 
on  the  addition  of  alcohol. 

Uric  acid  produces  an  undefined  pink  ring,  but  it  is  not 
exactly  at  the  line  of  contact,  and  is   redissolved  on  the 
application  of  heat. 
Johnson's  Test. — Fill  a  six-inch  test-tube  two-thirds  full 


THE    URINE.  127 

of  filtered  urine,  and  allow  a  couple  of  drams  of  a  clear, 
saturated  solution  of  picric  acid  to  flow  down  the  side  of  the 
tube  and  to  mix  with  the  urine.  Turbidity  indicates  the 
presence  of  albumin,  and  it  increases  on  gently  heating  the 
tube  near  its  mouth.  Certain  substances  in  the  urine,  Hke 
the  alkaloids,  produce  a  similar  turbidity,  but  this  disap- 
pears on  the  application  of  heat. 

Roberts's  Nitric  Magnesium  Test. — This  test  is  very  deli- 
cate and  rehable.  The-  test-fluid  is  made  by  adding  one 
volume  of  strong  nitric  acid  to  five  volumes  of  a  saturated 
solution  of  sulphate  of  magnesium,  and  is  employed  in 
the  same  manner  as  nitric  acid  in  Heller's  test. 

Acetonuria. — Acetone  is  probably  derived  chiefly  from 
the  fats  through  the  intermediary  stages  first  of  /9-oxybu- 
tyric  acid  and  then  of  diacetic  acid.  It  occurs  in  the  urine — 
( I )  To  a  very  slight  extent  in  health  ;  (2)  in  diabetes  mellitus  ; 
(3)  in  starvation ;  (4)  in  chloroform  narcosis  ;  (5)  in  some 
cases  of  carcinoma  ;  (6)  in  certain  digestive  disturbances. 

LegaVs  Acetone  Test. — To  4  c.c.  of  urine,  rendered  alka- 
line with  liquor  potassae,  add  a  few  drops  of  a  strong  solu- 
tion of  sodium  nitroprussid.  If  the  red  color  produced 
turns  purple  on  the  addition  of  a  few  drops  of  concentrated 
acetic  acid,  acetone  is  present. 

Diaceturia. — Diacetic  acid  is  found  in  the  urine  under 
the  same  conditions  as  acetone.  The  occurrence  of  diace- 
turia in  diabetes  is  favored  by  a  too  rigorous  meat  diet. 

Test  for  Diacetic  Acid. — Add  a  solution  of  ferric  chlorid  to 
urine  that  has  not  been  boiled.  If  diacetic  acid  is  present, 
a  Burgundy-red  color  develops. 

Beta-Oxybutyria. — Beta-oxybutyric  acid  is  found  often 
in  the  urine  with  diacetic  acid.  It  is  thought  to  be  the 
cause  of  diabetic  coma. 

Hematuria. — Blood  in  the  urine.  The  chief  causal 
conditions  are:  (i)  Traumatism;  (2)  acute  inflammation  of 
any  part  of  the  genito-urinary  tract — kidneys,  bladder, 
urethra ;  (3)  calculi  in  the  bladder  or  kidney  ;  (4)  conges- 
tion of  the  kidneys  from  chronic  heart,  lung,  or  liver  dis- 
ease ;  (5)  conditions  seriously  affecting  the  blood,  such  as 
the  specific  fevers,  scurvy,  malaria,  pernicious  anemia,  etc. ; 
(6)  tumors  and   tubercle   of  the   kidney   or  bladder;    (7) 


i2S  DISEASES   OF  THE  KIDNEYS 

varicose  veins  at  the  neck  of  the  bladder  (occasionally  seen 
in  old  persons) ;  (8)  vicarious  menstruation  (very  rare)  •  (o) 
parasites  in  the  genito-urinary  tract,  such  as  the  Filaria 
sanguinis  hominis  and  Distoma  haematobium 

Diagnosis.— By  the  color  of  the  urine  and  by  microscopic 
and  spectroscopic  examination. 

Heller's  Test.~^o\\  the  urine  with  a  solution  of  caustic 
potash:  phosphates  are  precipitated,  which  assume  a  red 
color  from  the  freed  hematin. 

Source  of  Hemorrhage.— ^r^/^r^._The  urine  first  passed 
IS  bloody,  and  the  other  symptoms  point  to  the  urethra 

Bladder. ~^\^it^xng  often  at  the  end  of  micturition  and 
other  symptoms  point  to  the  bladder. 

Kidney, —?,\oo^  intimately  mixed.     There  may  be  blood- 
ca^s  or  clots  and  the  other  symptoms  point  to  the  kidneys 
Hemog-lobmuria.- Blood-pigment  in  the   urine      The 
chief  causal  conditions  are— (i)    Blood  disintegration  from 
acute  infections  (malaria,  typhoid  fever,  yellow  fever),  scurvy 
purpura,  or  poisons  (potassium  chlorate,  carboHc  acid  etc  )• 
(2)  absorption  of  hemorrhagic  effusions  and  the  transfusion 
o\  blood ;  (3)  some   cases  of  Raynaud's  disease.     It  occa- 
sionally results  from  exposure  or  overexertion  (paroxysmal: 
fieinoglobimiria). 

Indicanuria.— Indican,  or  potassium  indoxyl  sulphate 
is  a  product  of  indol  derived  from  the  bacterial  decompo- 
sition of  proteids  in  the  intestine.  It  does  not  color  the 
urine,  but  by  oxidation  it  is  converted  into  indigo-blue.  It 
IS  a  constituent  of  normal  urine.  It  is  increased  (i)  in  all 
conditions  which  favor  putrefaction  in  the  upper  bowel  as 
obstruction  in  the  small  intestine,  acute  and  chronic  peri- 
tonitis, typhoid  fever,  intestinal  catarrh,  and  obstructive 
jaundice;  (2)  conditions  associated  with  the  decomposition 
of  pus,  as  empyema,  abscess,  and  gangrene  of  the  lung. 

Tests  for  Indican.— Wyk  equal  volumes  of  urine  and  fum- 
ing hydrochloric  acid,  and  with  constant  shaking,  add  a 
fresh,  saturated  solution  of  calcium  hypochlorite,  drop  by 
drop,  until  the  blue  color  ceases  to  deepen,  then  shake  with 
chloroform.  The  latter  dissolves  the  indigo  and  separates 
as  a  blue  hquid,  the  color  of  which  is  more  or  less  deep 
according  to  the  amount  of  indican. 


THE    URINE.  129 

Choluria. — The  presence  of  bile-pigments  and  bile  acids 
in  the  urine.  It  is  most  marked  in  obstructive  jaundice, 
but  it  may  also  occur  in  the  non-obstructive  form.  The 
urine  varies  from  a  greenish-yellow  to  a  dark-brown   color. 

Tests  for  Bile. — Gmelin's  Test. — Allow  a  few  drops  of 
urine  and  a  few  drops  of  fuming  nitric  acid  to  come  together 
on  a  white  plate.  If  bile  is  present,  there  will  be  an  iri- 
descent play  of  colors — green,  blue,  violet,  and  red — at  the 
line  of  contact. 

Pettenkofer' s  Test. — Add  a  few  grains  of  cane-sugar  and 
a  drop  of  sulphuric  acid  to  the  suspected  urine  in  a  test- 
tube  ;  heat  gently,  and  if  bile  acids  are  present,  a  violet-red 
color  is  produced. 

Hay's  Test. — If  a  very  small  amount  of  flowers  of  sulphur 
be  sprinkled  upon  the  surface  of  the  urine,  it  will  at  once 
begin  to  fall  to  the  bottom  if  the  slightest  traces  of  bile  are 
present. 

Chyluria. — Chyle  in  the  urine.  The  urine  presents  a 
milky  appearance.  The  emulsion  of  the  fat  is  so  complete 
that  microscopic  examination  rarely  reveals  distinct  oil- 
globules.  Ether  dissolves  the  fat  and  renders  the  urine 
clear.  Chylous  urine  is  often  slightly  pink  from  the  admix- 
ture of  blood.  The  chief  cause  of  chyluria  is  the  obstruction 
of  the  lymphatic  ducts  by  the  Filaria  sanguinis  hominis. 

Pyuria. — Pus  in  the  urine.  It  results  (i)  from  suppura- 
tive inflammation  of  any  part  of  the  genito-urinary  tract, 
and  (2)  from  the  rupture  of  abscesses  into  the  tract. 

It  appears  as  a  dull,  greenish-yellow  precipitate  that  is 
converted  into  a  clear  gelatinous  mass  by  the  addition  of 
liquor  potassae.    It  can  always  be  detected  by  the  microscope. 

Source. — When  pus  is  from  the  kidney,  it  is  intimately 
mixed  with  the  urine ;  the  latter  has  an  acid  or  neutral 
reaction,  and  the  associated  symptoms  point  to  the  kidneys. 

When  the  pus  is  from  the  bladder,  it  is  not  so  intimately 
mixed  with  the  urine;  the  latter  is  often  alkaline  in  reaction, 
and  the  associated  symptoms  point  to  the  bladder. 

l^hrlich'S   Dia^o-reaction. — In    certain    diseases   the 
urine  contains  aromatic  bodies  that  produce  a  characteristic 
color  with  sulpho-diazobenzol. 
9 


130  DISEASES   OF  THE  KIDNEYS. 

Process. — Two  solutions  should  be  prepared  and  kept  in  separate  bottles: 
I.  Sulphanilic  acid  ....         5.0  2.  Sodium  nitrite  .   .    .       0.5 

Hydrochloric   acid,    pure     50.0  Distilled  water     .    .  ico  o 

Distilled  water looo.o 

In  order  to  apply  the  test,  50  c.c.  of  No.  i  are  added  to  I  c.c.  of  No.  2. 
The  mixture  is  added  to  the  urine  in  a  test-tube  in  the  proportion  of  half  urine 
and  half  mixture.  One  c.c.  of  ammonia-water  is  then  added  and  the  test-tube 
is  violently  shaken.  The  reaction  is  positive  only  when  the  resulting  froth 
acquires  a  rose-red  (not  brown)  color. 

The  diazo-reaction  is  commonly  pi'esent  in  typhoid  fever. 
Its  vakie  in  diagnosis  is  lessened  by  its  frequent  occurrence 
in  tuberculosis,  measles,  pneumonia,  and  septic  diseases. 

FLOATING  KIDNEY. 

(Movable  Kidney ;  Nephroptosis.) 

Definition. — A  condition  in  which  the  kidney  manifests 
a  high  degree  of  mobility. 

!^tiology. — It  is  much  more  frequent  in  women  than  in 
men.  Tight  lacing,  frequent  pregnancies,  rapid  loss  of  flesh, 
and  overexertion  are  reputed  causes.  Congenital  laxity  of 
the  perinephric  tissues  is  probably  the  chief  factor. 

Symptoms. — The  right  kidney  is  the  one  usually 
affected,  probably  from  its  relation  to  the  liver,  which  moves 
during  the  respiratory  acts.  The  kidney  may  be  found  in 
any  part  of  the  abdomen  as  a  movable  tumor,  reniform  in 
shape,  somewhat  tender  to  the  touch,  and  rarely  imparting 
the  pulsation  of  the  renal  artery.  Not  infrequently  gastrop- 
tosis  and  enteroptosis  coexist. 

There  may  be  no  subjective  symptoms.  In  many  cases, 
however,  there  is  a  sense  of  discomfort  in  the  abdomen, 
accompanied  by  digestive  distui-bance,  hysteric  manifesta- 
tions, and  hypochondriasis.  Occasionally  painful  parox- 
ysms occur  simulating  renal  colic  (Dietl's  crises).  These 
have  been  attributed  to  engorgement  of  the  kidney  from 
twisting  of  the  renal  vessels. 

Diagnosis. — The  reniform  shape  of  the  tumor,  its  free 
mobility,  its  stationary  size,  the  lessened  resistance  on  per- 
cussion over  the  renal  region  of  the  affected  side,  and  the 
absence  of  cachexia  will  serve  to  diagnose  a  floating  kidney 
from  other  abdominal  tumors. 


HYPEREMIA    OF   THE   KIDNEY.  I3I 

Treatment. — In  many  cases  regulation  of  the  diet,  the 
avoidance  of  undue  exertion,  and  the  appHcation  of  a  broad 
abdominal  binder  will  suffice.  When  the  distressing  symp- 
toms persist  and  prove  disabling,  nephrorrhaphy  (stitching 
the  kidney  to  the  posterior  abdominal  wall)  should  be  con- 
sidered. 

HYPEREMIA  OF  THE  KIDNEYS- 
Varieties. — (i)  Active  hyperemia ;  (2)  passive  hyperemia. 

ACTIVE  HYPEREMIA. 

I^tiology. — It  may  be  due  to  exposure  to  cold;  to 
poisons  (cantharides,  turpentine,  copaiba,  etc.) ;  to  the  acute 
fevers  ;  or  to  pregnancy. 

Pathology. — The  kidneys  are  swollen,  red,  and  bleed 
freely  on  section.  Microscopic  examination  reveals  engorge- 
ment of  the  capillaries  and  cloudy  sw^elling  of  the  epithehum. 

Symptoms. — The  urine  is  scanty  and  may  contain  a 
small  amount  of  albumin  and  a  few  hyaline  casts.  There  is 
no  edema. 

Treatment. — The  patient  should  be  kept  in  bed  for  a 
few  days.  The  diet  should  consist  of  milk.  Wet-cups  and 
hot  applications  over  the  kidney  region  afford  relief  Saline 
purges  and  vapor-baths  are  efficacious. 

PASSIVE  HYPEREMIA, 

Ktiology. — It  is  most  commonly  caused  by  chronic 
heart  and  lung  diseases  which  impede  the  circulation.  It 
may  be  due  to  pressure  on  the  renal  veins  by  tumors,  ascitic 
fluid,  or  the  pregnant  uterus.  It  occasionally  results  from 
thrombosis  of  the  renal  veins  or  inferior  vena  cava. 

Pathology. — The  kidneys  are  swollen,  firm,  and  of  a 
dark-red  color.  The  Malpighian  bodies  are  distinctly  visible. 
Long-standing  passive  congestion  leads  to  pigmentation 
and  to  hyperplasia  of  connective  tissue  (cyanotic  indjiratiori). 

Sym.ptoms. — The  urine  is  scanty,  dark,  and  of  high 
specific  gravity  (1030  to  1035).  It  contains  a  small  amount 
of  albumin  and   often   a  few  hyahne   casts   and  a  few  red 


132  DISEASES   OF   THE   KIDNEYS. 

blood-cells.  Symptoms  of  the  primary  disease  which  has 
caused  the  general  venous  stasis  (dyspnea,  cyanosis,  and 
edema)  are  often  superadded.     Uremia  does  not  occur. 

Prognosis. — This  depends  upon  the  gravity  of  the  pri- 
mary disease. 

Treatment, — The  patient  should  be  kept  at  rest.  The 
diet  should  consist  chiefly  of  milk  and  farinaceous  food. 
Dry  cupping  is  of  service.  As  a  diuretic,  infusion  of  digi- 
talis (2  to  4  drams)  is  distinctly  useful.  Hydragogue 
cathartics  (salines  and  compound  jalap  powder)  may  be 
employed  as  adjuvants.  In  chronic  heart  disease  such  a  pill 
as  the  following  may  be  of  service : 

R.     Pulveris  digitalis 

Pulveris  scillae .    .    .   aa  gr.  xx 

Extracti  nucis  vomicae gi".  iv 

Massse  ferri  carbonatis   .......    gr.  xxx. — M. 

Fiant  in  pilulae  No.  xx. 

SiG. — One  pill  four  times  a  day. 

UREMIA* 

Definition. — The  name  applied  to  a  group  of  symptoms 
resulting  from  the  retention  of  poisons  in  the  blood  which 
should  have  been  eliminated  by  the  kidneys. 

Symptoms. — It  may  develop  slowly  or  abruptly  in  any 
form  of  nephritis,  and  may  be  manifested  by  any  of  the 
following  phenomena :  Headache,  vertigo,  delirium,  epilep- 
tiform convulsions,  coma,  sudden  blindness  (unassociated 
with  any  retinal  change),  and  transient  paralysis  from 
congestion  or  edema  of  the  brain  or  spinal  cord. 

Pulmonary  Symptoms. — Dyspnea  (uremic  asthma),  Cheyne- 
Stokes  breathing. 

Gastro-intestinal  Symptoms. — Hiccup,  obstinate  vomiting, 
and  purging. 

General  Symptoms. — The  skin  is  dry,  the  breath  has  a 
urinous  odor,  the  pulse  is  slow  and  often  of  high  tension, 
and  the  urine  is  scanty  or  suppressed.  The  temperature  is 
usually  normal  or  subnormal,  but  slight  fever  is  not  un- 
common. 

Diagnosis. — The  urinous  odor  of  the  breath,  the  scanty 
urine,  the   decreased    urea   excretion,   and  the   associated 


ACUTE  NEPHRITIS.  133 

symptoms  of  nephritis  will  usually  lead  to  a  correct  diag- 
nosis. The  differentiation  of  uremic  coma  from  other  forms 
of  coma  is  considered  on  page  376. 

Prognosis. — This  is  always  grave.  Recovery  is  pos- 
sible, however,  even  after  the  most  severe  symptoms. 

Treatment. — The  chief  indication  is  to  favor  elimination. 
Two  drops  of  croton  oil,  diluted  with  olive  oil  or  glycerin, 
or  \  grain  of  elaterium,  should  be  given  at  once.  Sweating 
should  be  promoted  by  hot-air  or  vapor  baths  and  the 
hypodermic  administration  of  pilocarpin.  If  coma  or  con- 
vulsions appear,  and  the  patient  is  not  too  feeble,  venesec- 
tion may  be  practised,  the  removal  of  from  1 5  to  20  ounces  of 
blood  sometimes  exerting  a  very  happy  effect.  In  children 
a  few  ounces  of  blood  may  be  abstracted  from  the  loins  by 
means  of  wet-cups. 

After  the  blood  has  been  withdrawn,  normal  saline  solu- 
tion may  be  injected  subcutaneously.  Rectal  irrigation 
with  hot  sahne  solution  is  another  potent  measure.  Con- 
vulsions may  be  controlled  by  chloroform  inhalations  or 
by  an  enema  of  chloral  (J  to  i  dram).  Morphin  has  been 
recommended,  but  it  should  be  used  with  great  caution, 
especially  in  chronic  interstitial  nephritis, 

ACUTE  NEPHRITIS, 

(Acute  Bright's  Disease ;  Acute  Tubular  Nephritis ;  Acute  Des- 

quamative  Nephritis ;  Acute  Parenchymatous  Nephritis ;  Acute 

Catarrhal  Nephritis.) 

Definition. — An  acute  inflammatory  disease  of  the  kid- 
ney, involving  especially  the,  epithelium  of  the  tubules  and 
glomeruli. 

:Etiology. — The  chief  causes  are  :  (i)  Infectious  diseases, 
especially  scarlet  fever ;  (2)  poisons  which  are  eliminated 
through  the  kidneys,  such  as  cantharides,  turpentine,  etc.; 
(3)  exposure  to  cold  and  wet ;  (4)  pregnancy.  Inflamma-. 
tory  skin  diseases  and  extensive  burns  may  also  cause 
acute  nephritis. 

Pathology.— The  kidney  is  swollen  and  the  capsule 
non-adherent.     At  first  the  organ  is  bright  red  in  color ;  it 


134  DISEASES   OF  THE  KIDNEYS. 

soon,  however,  becomes  pale  and  mottled  in  appearance, 
although  the  Malpighian  tufts  still  retain  their  deep-red  tint. 

Histology. — The  epithelium  of  the  tubules  and  glom- 
eruH  is  the  seat  of  cloudy  swelling  and,  later,  of  fatty 
degeneration.  Desquamated  epithelium,  blood-corpuscles, 
and  an  albuminous  exudate  block  the  tubules.  The  capil- 
laries are  dilated,  their  walls  are  degenerated,  and  bloody 
extravasations  are  not  infrequently  seen.  The  interstitial 
tissue  is  more  or  less  infiltrated  with  leukocytes. 

Symptoms. — The  general  symptoms  are  moderate  fever 
and  its  associated  phenomena ;  dull  lumbar  pain ;  nausea 
and  vomiting ;  dropsy,  beginning  in  the  face  and  becoming 
general ;  and  pronounced  anemia.  Uremic  symptoms  may 
develop  at  any  time. 

The  Urine. — The  urine  is  scanty  and  at  times  suppressed. 
It  is  smoky  in  appearance,  of  high  specific  gravity,  and  con- 
tains a  large  amount  of  albumin,  free  blood,  hyaline,  blood, 
and  epithelial  casts,  and  epithelial  cells.  Granular  casts 
may  also  be  found.     The  daily  secretion  of  urea  is  decreased. 

Diagnosis. — As  the  general  symptoms  are  often  slight, 
the  diagnosis  must  rest  on  the  examination  of  the  urine. 
The  history  and  the  absence  in  the  urine  of  wide,  highly 
fatty  casts  will  serve  to  distinguish  acute  nephritis  from  an 
acute  exacerbation  of  chronic  parenchymatous  nephritis. 

Prognosis. — Guardedly  favorable.  It  may  kill  by  ex- 
haustion, uremia,  or  edema  of  the  lungs.  It  may  become 
chronic.     The  average  duration  is  from  two  to  six  weeks. 

Treatment. — -Absolute  rest  in  bed  for  from  four  to  six 
weeks  is  imperative.  Milk  largely  diluted  with  carbonated 
water,  Vichy,  or  lime-water  is  the  best  food.  Beef-tea  and 
broths  should  be  interdicted. 

In  the  absence  of  any  direct  remedies  the  indications  are 
to  divert  the  blood  from  the  inflamed  kidneys,  to  lessen 
their  work  as  much  as  possible  by  increasing  the  action  of 
the  bowels  and  skin,  and  to  meet  the  symptoms  as  they 
arise. 

At  the  onset,  if  there  be  pain  or  suppression  of  urine, 
dry  cupping,  or,  in  severe  cases,  wet  cupping  over  the 
region  of  the  kidneys   is  of  value.     Following  the  cupping 


CHRONIC  PARENCHYMATOUS  NEPHRITIS.  1 35 

warm  poultices  may  be  applied  to  the  loins  with  advantage. 
Cantharides,  turpentine,  or  similar  drugs  are  not  to  be  used. 

The  bowels  should  be  kept  freely  opened  by  means  of 
daily  purges,  the  best  being  salines  in  concentrated  solu- 
tion and  compound  jalap  powder  (20  to  30  grains). 

Free  sweating  is  very  useful  in  promoting  elimination  by 
the  skin.  It  may  be  effected  by  means  of  hot-water  baths, 
hot  packs,  vapor-baths,  hot-air  baths,  or  the  subcutaneous 
administration  of  pilocarpin  {^^  to  \  grain). 

Unirritating  diuretics,  like  digitalis  and  potassium  citrate 
or  acetate,  are  useful.  These  drugs  may  be  combined,  as  in 
the  following  formula  : 

R.    Potassii  acetatis ^ij 

Infusi  digitalis ^.I'ij- — M. 

SiG. — A  tablespoonful,  well  diluted,  thrice  daily. 

Excessive  dropsy  may  demand  puncture  of  the  swollen 
parts,  a  free  incision  at  the  outer  side  of  each  ankle,  or 
the  insertion,  beneath  the  skin,  of  delicate  silver  cannulae 
(Southey's  tubes).  Uremia  will  call  for  its  appropriate  treat- 
ment (see  p.  1 1 3).  After  the  acute  symptoms  have  sub- 
sided, iron  may  be  employed  in  the  form  of  Basham's 
mixture  (2  to  4  fluidrams)  to  combat  anemia. 

CHRONIC  PARENCHYMATOUS  NEPHRITIS. 

(Chronic  Catarrhal  Nephritis;  Large  White  Kidney.) 

Ktiology. — It  may  follow  acute  nephritis  or  it  may  be 
chronic  from  the  beginning.  Habitual  exposure,  abuse  of 
alcohol,  chronic  infections  (tuberculosis,  malaria),  and  pas- 
sive congestion  are  predisposing  factors.  It  occurs  most 
often  between  the  ages  of  twenty  and  forty. 

Pathology. — In  the  early  stages  the  kidney  is  enlarged 
and  of  a  yellowish  color.  The  capsule  strips  easily  {large 
white  kidney).  Microscopically,  the  epithelium  of  the 
tubules  and  Malpighian  bodies  shows  advanced  fatty  degen- 
eration. The  connective  tissue  is  somewhat  proliferated. 
Hemorrhagic  extravasations  are  frequently  seen.  In  the 
second  stage  {fatty  contracting  kidney)  the  organ  is  small 
and  pale ;  its  surface  is  uneven,  and  its  capsule  is  somewhat 


136  DISEASES   OF  THE  KIDNEYS. 

adherent.  The  reduced  size  depends  on  destruction  of  the 
renal  epitheh'um  and  the  contraction  of  the  overgrown  con- 
nective tissue. 

Symptoms. — The  symptoms  usually  develop  insidiously 
and  consist  in  progressive  weakness,  marked  anemia,  dropsy 
(often  first  noted  in  the  face  on  rising  in  the  morning),  diges- 
tive disturbances,  and  sooner  or  later  a  moderate  degree  of 
cardiac  hypertrophy  with  high  arterial  tension  and  accentua- 
tion of  the  second  aortic  sound.  Uremic  symptoms  may 
develop  at  any  time. 

The  Urine. — The  urine  is  usually  diminished  in  quantity, 
is  often  turbid,  is  of  rather  low  specific  gravity,  is  highly 
albuminous,  and  contains  wide  dark  granular  casts,  fatty 
casts,  waxy  casts,  and  fatty  epithelial  cells. 

Com.plications. — These  are  numerous  and  often  suggest 
the  diagnosis.  The  most  common  are  uremia,  extensive 
serous  effusion  into  the  tissues  or  serous  cavities,  latent 
inflammation  of  the  serous  membranes,  pneumonia,  valvular 
heart  disease,  albuminuric  retinitis,  apoplexy,  and  acute  ex- 
acerbations. 

Prognosis. — Unfavorable.  The  duration  is  from  a  few 
months  to  several  years. 

Treatment. — The  treatment  is  largely  dietetic  and 
hygienic.  Residence  in  a  dry,  warm,  and  equable  climate 
serves  to  prolong  life.  Rest  is  an  essential  element  in  the 
treatment.  The  underclothing  should  be  woollen  or  silk. 
The  diet  should  be  non-nitrogenous,  and  in  severe  cases  an 
absolute  milk  diet  may  be  of  extreme  value.  Warm  baths 
with  friction  are  useful  in  promoting  free  action  of  the  skin, 
but  great  care  must  be  exercised  after  their  use  to  avoid 
chilling.  The  bowels  should  be  kept  active  by  natural 
mineral  waters  or  saline  laxatives.  When  the  urine  is 
scanty,  digitalis,  caffein,  potassium  citrate,  or  theobromin 
may  prove  efficacious.  The  following  combination  some- 
times acts  happily  : 

R.     Sparteinse  sulphatis      g^"-  vj 

Caffeinae  citratse gr.  xxx 

Lithii  benzoatis        ^j. — M. 

Fiant  chartulae  No.  xij. 

SiG. — One  powder  four  times  a  day. 


CHRONIC  INTERSTITIAL   NEPHRITIS.  1 37 

Basham's  mixture  is  often  useful  as  a  hematinic,  but  only 
small  doses  should  be  used.  Strychnin  and  the  simple 
bitters  are  valuable  adjuvants  to  iron  in  many  cases.  Ex- 
cessive dropsy  will  call  for  hydragogue  cathartics  (Epsom 
salts,  compound  jalap  powder,  or  elaterium),  for  diaphoretics 
(hot-air  baths  and  pilocarpin),  and  perhaps  for  operative 
measures  (puncture  of  the  legs  and  scrotum,  insertion  of 
Southey's  tubes,  incisions  near  the  ankles,  aspiration  of 
serous  sacs).  Uremia  will  demand  special  treatment  (see 
p.  113);  acute  exacerbations  should  be  treated  as  primary 
attacks  of  acute  nephritis. 

CHRONIC  INTERSTITIAL  NEPHRITIS* 
(Red  Granular  Kidney;  Contracted  Kidney;  Gouty  Kidney.) 

Definition. — A  chronic  inflammatory  disease  of  the 
kidney  characterized  by  a  marked  overgrowth  of  its  con- 
nective-tissue elements,  and  almost  invariably  associated 
with   general  arteriosclerosis  and  hypertrophy  of  the  heart. 

!^tiology. — It  is  much  more  common  in  males  than  in 
females,  and  is  most  frequently  encountered  between  the 
ages  of  forty  and  sixty,  (i)  It  is  frequently  a  sequel  of  gout, 
chronic  rheumatism,  alcoholism,  chronic  plumbism,  or  syph- 
ilis ;  (2)  it  is  a  common  accompaniment  of  arteriosclerosis  ; 
(3)  it  may  follow  passive  congestion,  as  from  chronic  heart 
disease. 

Pathology. — The  kidney  is  small  and  red  in  color.  The 
surface  is  granular  and  the  capsule  adherent.  The  organ  is 
firm,  cuts  with  difficulty,  and  on  section  often  reveals  small 
cysts  or  calcareous  deposits.  The  cortical  substance  is 
greatly  reduced  in  thickness.  Microscopic  examination 
shows  an  overgrowth  of  connective  tissue,  which  in  con- 
tracting has  partially  destroyed  the  glomeruli  and  narrowed 
the  lumen  of  the  tubules.  The  epithelium  also  is  more  or 
less  atrophied  and  degenerated.  The  arteries  throughout 
the  body  are  the  seat  of  sclerotic  changes,  in  consequence  of 
which  hypertrophy  of  the  heart,  especially  of  the  left  ventri- 
cle, has  resulted. 

Symptoms. — The  symptoms  develop  most  insidiously. 


138  DISEASES   OF   THE  KIDNEYS. 

There  is  slow  loss  of  strength,  with  increasing  anemia. 
Gastric  disturbances  are  common.  Vascular  symptoms  are 
prominent,  and  include  thickening  of  the  vessels,  high 
arterial  tension,  accentuation  of  the  second  aortic  sound,  and 
hypertrophy  of  the  heart.  Dyspnea  is  present  in  the  late 
stages,  and  may  result  from  cardiac  weakness,  edema  of  the 
lungs,  or  uremia.  Headache,  vertigo,  and  insomnia  often 
result  from  the  disturbed  circulation  or  from  uremia.  Dim- 
ness of  vision  from  albuminuric  retinitis  is  a  serious  symp- 
tom. Dropsy  is  often  absent,  or  is  slight  and  late  in 
appearing.     Uremia  is  of  very  frequent  occurrence. 

The  Urine. — The  urine  is  very  copious  (80  to  150  ounces), 
pale  in  color,  of  low  specific  gravity, — 1005  to  1012, — and 
contains  but  a  trace  of  albumin  and  few  narrow  hyaline  or 
pale  granular  casts. 

Complications. — Albuminuric  retinitis,  valvular  heart 
disease,  apoplexy  resulting  from  the  weakened  arteries  and 
large  heart,  uremia,  latent  inflammation  of  serous  mem- 
branes, pneumonia,  and   bronchitis. 

Diagnosis. — Chronic  parenchymatous  nephritis  usually 
occurs  in  younger  subjects  and  runs  a  shorter  course. 
There  is  decided  edema,  and  the  urine  is  decreased  in  quan- 
tity and  contains  much  albumin  and  wide  fatty  casts. 

Prognosis. — The  disease  is  incurable,  but  may  last  many 
years.  The  possibility  of  uremia  occurring  suddenly  must 
be  borne  in  mind. 

Treatment. — The  dietetic  and  hygienic  treatment  is  that 
of  chronic  parenchymatous  nephritis.  Frequent  tepid  baths 
with  friction  of  the  skin  are  advantageous.  The  bowels 
should  be  kept  regular  with  mild  saline  cathartics  or  alka- 
line mineral  waters.  Nitroglycerin  (yi-o  ^^  sV  g^^i'^)  i^  often 
useful  when  arterial  tension  becomes  excessive  and  causes 
headache,  vertigo,  palpitation,  and  dyspnea.  Basham's  mix- 
ture in  small  doses  (i  fluidram)  is  sometimes  of  service  when 
there  is  pronounced  anemia.  When  there  is  severe  insom- 
nia, bromids,  chloral,  paraldehyd,  and  trional  may  be  tried 
in  the  order  named.  Opium  should  be  avoided.  Heart- 
failure  with  low  arterial  tension  will  require  the  use  of  such 
stimulants  as  digitahs,  strychnin,  caffein,  and  alcohol. 


PYELITIS.  139 

AMYLOID  DEGENERATION  OF  THE  KIDNEY. 

(Waxy  Kidney ;  Lardaceous  Kidney.) 

etiology. — It  occurs  in  prolonged  suppurative  diseases, 
especially  of  bones,  in  tuberculosis,  syphilis,  and  cachectic 
states. 

Pathology. — The  kidney  is  enlarged,  firm,  and  pale,  and 
on  section  may  present  a  waxy,  translucent  appearance. 
The  amyloid  areas  are  colored  mahogany-brown  by  the 
application  of  Lugol's  solution  to  the  cut  surface.  Other 
organs,  especially  the  liver  and  spleen,  usually  share  in  the 
degenerative  process. 

On  microscopic  examination  the  walls  of  the  blood-ves- 
sels, especially  of  those  of  the  Malpighian  bodies,  are  found 
thickened  and  infiltrated  with  a  homogeneous  wax-like 
material  that  turns  pink  when  treated  with  gentian-violet. 
The  epithelium  is  often  fatty. 

Symptoms. — Most  patients  appear  badly  nourished  and 
anemic.  Dropsy  is  present  in  many  cases.  The  liver  and 
spleen  are  usually  enlarged  from  the  same  cause.  Uremia 
is  very  rare. 

The  Urine. — The  urine  is  increased  in  quantity,  is  rich  in 
albumin,  and  is  of  low  specific  gravity.  Microscopically,  it 
contains  hyaline  and  waxy  tube-casts  and  degenerated 
epithelium. 

Diagnosis. — This  is  based  upon  the  history,  the  en- 
largement of  the  liver  and  spleen,  and  the  polyuria  with 
marked  albuminuria. 

Prognosis. — In  the  majority  of  cases  the  prognosis  is 
very  grave.  In  the  early  stages  an  arrest  of  the  process  is 
not  impossible  if  the  original  disease  can  be  cured. 

Treatment. — The  treatment  is  chiefly  that  of  the  pri- 
mary disease.  In  other  respects  it  must  be  purely  hygienic, 
dietetic,  and  symptomatic. 

PYELITIS* 

Definition. — Inflammation  of  the  pelvis  of  the  kidney. 
Btiology. — (i)  It  may  result  from  a  stone  in  the  pelvis 
of  the  kidney  (calculous  pyelitis).     (2)  It  may  be  secondary 


I40  DISEASES   OF   THE  KIDNEYS. 

to  urethritis  and  cystitis.  (3)  It  may  be  tuberculous  or 
cancerous.  (4)  It  may  be  excited  by  irritant  diuretics — 
cantharides,  turpentine,  etc.  (5)  It  may  occur  in  the  course 
of  specific  fevers.  (6)  It  is  rarely  the  result  of  exposure  to 
cold  and  wet. 

Pathology. — The  mucous  membrane  is  swollen,  in- 
jected, and  covered  with  desquamated  epithehum  and 
mucus  or  mucopus.  In  severe  cases  the  suppurative  in- 
flammation may  extend  to  the  substance  of  the  kidney 
^pyelonephritis).  In  calculous  and  tuberculous  pyelitis, 
especially  when  the  ureter  is  obstructed,  the  pelvis  of  the 
kidney  may  become  greatly  distended  from  the  accumula- 
tion of  pus  (^pyonephrosis).  In  such  cases  the  pus  is  occa- 
sionally discharged  into  the  perinephric  tissues,  and  ulti- 
mately even  into  the  colon  or  other  neighboring  organs. 

Symptoms. — In  simple  catarrhal  pyelitis  the  chief  symp- 
toms are  dull  pain  over  the  kidney  and  the  passage  of 
turbid,  acid  urine,  containing  mucus,  epithelial  cells,  and 
pus-corpuscles.  In  severe  siippiirative  cases  the  kidney 
region  is  often  distinctly  painful  and  tender.  A  tumor  or 
swelling  can  sometimes  be  detected.  Symptoms  of  sepsis — 
irregular  fever,  profuse  sweats,  chills,  leukocytosis,  and 
pallor — are  frequently  present.  The  urine  is  usually  acid 
in  reaction  and  contains  more  or  less  pus,  mucus,  blood, 
albumin,  and  desquamated  pelvic  epithehum. 

Diagnosis. — In  cystitis  pain  is  referred  to  the  hypogas- 
tric region,  there  is  frequent  micturition  with  dysuria,  and 
the  urine  is  more  likely  to  be  alkaline  in  reaction  than  acid. 

In  perinephritic  abscess  the  lumbar  swelling  is  usually 
more  circumscribed ;  the  superficial  tissues  are  often  edema- 
tous ;  and  the  urine  is  free  from  pus. 

Calculous  Pyelitis. — Sharp  pain,  increased  by  jarring  move- 
ments, and  reflected  down  the  ureters,  and  the  presence  of 
much  blood  in  the  urine  point  to  calculous  pyelitis. 

Tuberculous  pyelitis  may  be  recognized  by  the  history,  the 
presence  of  tuberculous  foci  in  other  organs,  and  the  dis- 
covery of  tubercle  bacilli  in  the  urine.  The  tuberculin  test 
may  also  aid  in  the  diagnosis. 

Prognosis. — Mild  forms  resulting  from  exposure  or  the 


NEPHR  OLITHIA  SIS.  1 4 1 

specific  fevers  usually  recover  in  a  few  weeks.  In  suppura- 
tive pyelitis  the  prognosis  is  grave,  although  recovery  may 
occur  under  operative  treatment. 

Treatment. — The  patient  should  be  kept  in  bed  and 
placed  upon  a  milk  diet.  In  acute  cases  warm  applications 
are  useful.  Alkalis  and  alkaline  mineral  waters  are  of 
service.  Such  a  combination  as  the  following  may  be  pre- 
scribed : 
< 

R.     Sodii  bromidi 

Sodii  bicarbonatis     .......     aa   gr.  clx 

Extract!  belladonnEe gi"-  iv 

Extract!  buchu ^j 

Syrupi  sarsaparillae  compositi  .    q.  s.  ad  f5iv. — M. 

SiG. — A  teaspoonful  in  water  three  or  four  times  a  day. 

Urotropin  (5  grains)  or  salol  (3  to  5  grains)  may  be  given 
for  its  antiseptic  effect.  Calculous  pyelitis  will  require  the 
treatment  indicated  for  renal  calculus.  In  suppurative  cases 
operative  interference  offers  the  only  hope  of  saving  Hfe. 

NEPHROLITHIASIS* 

(Renal  Calculus;  Gravel.) 

Definition. — Renal  calculi  are  concretions  formed  in  the 
kidney  by  the  precipitation  of  various  solid  constituents  of 
the  urine. 

i^tiology. — The  disease  is  more  common  in  males  than 
in  females.  Heredity  and  sedentary  habits  are  given  as 
predisposing  causes.  The  formation  of  stones  is  favored  by 
the  presence  in  the  urine  of  any  sparingly  soluble  substance 
in  excess.  Mucus,  blood,  pus,  or  epithelium  may  furnish 
the  nucleus. 

Pathology. — The  size  of  renal  concretions  varies  from 
that  of  coarse  sand  ("  gravel ")  to  that  of  a  large  bean.  The 
most  common  forms  are  those  composed  of — (i)  Uric  acid 
and  its  compounds ;  (2)  oxalate  of  lime ;  (3)  phosphate  of 
calcium  and  of  ammoniomagnesium  phosphate.  Stones 
composed  of  xanthin  and  cystin  are  rare. 

Uric  acid  are  the  most  common  calculi.  They  are  usually 
smooth,  of  a  reddish-brown  color,  and  comparatively  hard. 


142  DISEASES   OF   THE   KIDNEYS, 

Oxalate-of-lime  calculi  are  very  hard,  of  a  dark-brown  color, 
and  uneven  (mulberry  calculi).  Phosphatic  calculi  are  gray- 
ish-white in  color,  soft,  and  mortar-like. 

invents. — (i)  Small  particles  are  frequently  passed  with- 
out serious  disturbance.  (2)  Larger  concretions  may  be 
extruded  with  intense  pain  [i^enal  colic).  (3)  Calculi  may 
remain  in  the  pelvis  and  excite  pyelitis  or  pyelonephritis. 
(4)  They  may  obstruct  the  ureter  and  cause  hydronephrosis 
or  pyonephrosis. 

Symptoms. — Paiii  and  tenderness  in  the  kidney  region 
are  common  symptoms.  The  pain  is  aggravated  by  rough 
motion,  and  tends  to  radiate  along  the  ureter.  The  urine 
frequently  contains  blood,  pus,  epithelium,  and  crystals  indi- 
cating the  nature  of  the  stone. 

Symptoms  of  Sepsis. — Irregular  fever,  chills,  sweats,  leu- 
kocytosis, and  pallor  mark  the  occurrence  of  suppurative 
pyelitis.  Colic  is  excited  by  the  entrance  of  the  stone  into 
the  ureter. 

Renal  colic  is  characterized  by  intense  pain  radiating  from 
the  kidney  downward  into  the  groin,  thigh,  and  testicle. 
The  testicle  is  often  retracted.  There  are  often  nausea, 
vomiting,  and  collapse.  After  such  an  attack  the  urine 
may  contain  blood  or  particles  of  stone. 

Diagnosis. — In  biliary  colic  the  pain  radiates  to  the 
shoulder;  there  is  often  jaundice;  the  gall-bladder  is 
usually  tender  and  enlarged;  the  urine  is  negative;  a  stone 
may  be  found  in  the  stools. 

Prognosis. — In  uncomplicated  cases  the  prognosis 
should  be  guardedly  favorable. 

Treatment. — This  should  be  directed  to  the  underlying 
diathesis.  In  cases  of  uric-acid  calculi  alkalis  and  alkaline 
m.ineral  waters  are  useful.  A  quart  of  water  containing  40 
grains  of  potassium  bicarbonate  and  20  grains  of  lithium 
citrate  may  be  taken  daily.  Special  remedies,  like  piperazin, 
lycetol,  and  urosin,  have  been  recommended  as  solvents, 
but  they  are  of  doubtful  value.  When  phosphatic  calculi 
are  present,  benzoic  or  boric  acid  (5  to  15  grains  thrice 
daily)  may  be  employed  in  a  similar  manner. 

Operation  (nephrohthotomy,  nephrotomy,  or  nephrectomy) 


HYDRONEPHROSIS.  I43 

is  urgently  demanded  when  the  attacks  of  renal  colic  occur 
with  such  frequency  as  to  prove  disabling,  when  there  are 
evidences  of  severe  pyelitis,  or  when  there  is  reason  to 
believe  that  the  calculus  has  become  permanently  impacted 
in  the  ureter. 

Renal  Colic. — The  indications  are  to  relieve  the  pain  and 
to  relax  the  spasm.  This  is  best  accomplished  by  hypo- 
dermic injections  of  morphin  and  atropin,  coupled  with  hot 
baths  or  local  applications — hot  poultices  or  fomentations. 
If  the  pain  is  extreme,  it  may  be  desirable  to  administer 
chloroform.  Simple  diluents  should  be  given  freely.  In 
mild  attacks  full  doses  of  phenacetin  or  antipyrin,  with  an 
abundant  supply  of  hot  drinks,  may  suffice. 

HYDRONEPHROSIS> 

Definition. — Dilatation  of  the  pelvis  of  the  kidney  by 
retained  secretion. 

Etiology. — The  chief  causes  are  :  (i)  Congenital  stric- 
ture of  the  ureter.  (2)  Impaction  of  a  calculus  in  the  ureter. 
(3)  Abdominal  tumors  compressing  the  ureter.  (4)  Tu- 
mors growing  within  the  urinary  passages.  (5)  An  inflam- 
matory stricture  of  the  ureter  or  urethra. 

Pathology. — The  pelvis  reveals  all  grades  of  distention. 
In  extreme  cases  it  may  contain  several  quarts  of  fluid, 
which  is  at  first  urinous,  but  later  thin  and  watery.  There 
is  more  or  less  atrophy  of  the  renal  tissue. 

Symptoms. — Slight  distention  yields  no  symptoms.  In 
other  cases  a  tumor  slowly  develops  in  the  region  of  the 
affected  kidney.  On  palpation  it  is  elastic,  and  perhaps 
fluctuating;  on  percussion,  dull;  and  on  aspiration  it  yields 
a  clear  fluid,  which  usually  contains  urea  and  uric  acid. 

Diagnosis. — This  should  be  based  on  the  history,  the 
exclusion  of  other  abdominal  enlargements,  and  the  chemical 
analysis  of  the  fluid  obtained  by  aspiration. 

Prognosis. — When  the  disease  is  unilateral  and  the 
other  kidney  secretes  a  normal  amount  of  urine  containing 
a  normal  amount  of  urea,  the  prognosis  is  guardedly  favor- 
able. The  disease  may  end  fatally  in  consequence  of  rup- 
ture into  the  peritoneum  or  of  secondary  pyonephrosis. 


144  DISEASES   OF   THE   KIDNEYS. 

Treatment. — Large  accumulations  will  demand  surgi- 
cal treatment;  ^ small  ones  should  not  be  disturbed. 

TUBERCULOSIS  OF  THE  KIDNEY* 

etiology. — The  etiology  of  renal  tuberculosis  is  that  of 
tuberculosis  in  general.  Males  are  more  frequently  attacked 
than  females.  The  majority  of  cases  are  encountered  be- 
tween the  ages  of  twenty  and  forty  years. 

Pathology. — Two  forms  of  renal  tuberculosis  have 
been  recognized — the  miliary  and  the  caseous.  The  former 
is  nearly  always  bilateral,  is  an  acute  process,  and  is  gen- 
erally unmistakably  secondary  to  tuberculosis  elsewhere  in 
the  body.  The  caseous  variety  runs  a  chronic  course ;  it 
usually  begins  as  a  unilateral  affection,  although  the  other 
organ  is  commonly  ultimately  involved,  and  a  primary 
focus  may  or  may  not  be  apparent  in  some  other  structure. 

Symptoms. — The  chief  symptoms  are  :  pain  in  the  lum- 
bar region,  usually  dull,  but  sometimes  sharp,  Hke  that  of 
renal  colic ;  tenderness  on  pressure ;  slight,  irregular  fever, 
and  more  or  less  cachexia.  The  urine  is  usually  acid  in 
reaction,  and  may  contain  pus,  blood,  albumin,  tubercle 
bacilli,  cheesy  particles,  and  debris.  Tube-casts  are  rarely 
found.  In  many  cases  enlargement  of  the  affected  organ 
can  be  detected  by  bimanual  palpation. 

Diagnosis. — Calculous  Pyelitis. — In  this  condition  pain 
is  usually  more  severe  and  more  apt  to  be  affected  by 
movement.  Hematuria  is  more  profuse,  and  is  often  ex- 
cited by  exertion.  Cachexia  is  not  so  marked,  and  there 
are  no  tubercle  bacilli  in  the  urine.  The  tuberculin-test  and 
the  Rontgen  rays  may  aid  in  the  diagnosis. 

Prognosis. — Always  grave.  Without  intervention  the 
duration  is  from  a  few  months  to  three  years. 

Treatment. — When  the  renal  disease  appears  to  be 
primary  and  the  patient's  strength  will  permit,  nephrectomy 
should  be  recommended.  The  mortality  in  operative  cases 
has  been  about  28  per  cent.  In  other  cases  the  treatment 
must  of  necessity  be  palliative. 


DISEASES  OF  THE  BLOOD  AND  THE 
DUCTLESS   GLANDS. 


NORMAL  BLOOD. 

In  health  the  blood  amounts  to  about  one-thirteenth 
of  the  body-weight.  Normally  there  are  approximately 
5,000,000  red  blood-corpuscles  in  the  cubic  miUimeter. 
This  number  is  temporarily  diminished  during  menstrua- 
tion, gestation,  lactation,  and  fatigue,  and  after  the  ingestion 
of  much  fluid.  Fasting  and  profuse  sweating  increase  the 
number  of  red  cells  by  concentrating  the  blood.  In  the 
first  few  days  of  life  the  number  in  a  cubic  millimeter  may 
be  7,000,000  to  8,000,000.  In  high  altitudes  the  number  is 
also  increased.  There  are  from  5000  to  10,000  white  cells 
in  the  cubic  millimeter,  the  ratio  of  white  to  red  cells  being 
about  I  to  500.  The  number  of  blood-plates  is  from 
200,000  to  300,000. 

EXAMINATION  OF  THE  BLOOD. 

A  clinical  study  of  the  blood  has  for  its  object  the  deter- 
mination of  the  percentage  of  hemoglobin,  the  specific 
gravity,  the  alkalinity,  the  number,  form,  and  relative  pro- 
portion of  the  various  corpuscles,  and  the  detection  of  free 
pigment,  bacteria,  and  animal  parasites. 

Estimation  of  Hemoglobin. — The  percentage  of 
hemoglobin  may  be  determined  by  either  Fleischl's  or 
Gowers'  apparatus,  although  the  former  is  preferable. 

Gowers  hefjiogiobinometei^  consists  of — (i)  A  small  sealed 
tube  containing  coloring-matter  representing  the  color  of 
normal  blood  diluted  with  100  parts  of  water;  (2)  an  empty 
10  145 


146    DISEASES   OF  BLOOD   AND  DUCTLESS   GLANDS. 

tube  of  the  same  size,  graduated  up  to  120  per  cent;  (3)  a 
small  bottle  with  a  pipet  stopper,  for  distilled  water ;  (4)  a 
capillary  pipet  for  measuring  20  cm.  of  blood ;  and  (5)  a 
small  lancet.  To  obtain  a  specimen  of  blood  the  tip  of  the 
finger  or  the  lobe  of  the  ear,  after  being  thoroughly  cleansed, 
is  deeply  pricked  with  the  lancet,  so  that  the  blood  flovjs 
freely  without  squeezing ;  20  cm.  of  blood  are  then  drawn 
into  the  capillary  pipet,  and  are  immediately  blown  into  the 
graduated  tube,  in  which  have  been  previously  placed  a  few 
drops  of  distilled  water  to  prevent  coagulation.  After 
shaking  the  mixture  to  secure  diffusion  of  the  blood,  more 
distilled  water  is  cautiously  added,  with  occasional  shaking, 
until  the  tint  in  the  sealed  tube  is  reached.  The  height  of 
the  column  of  the  fluid  in  the  graduated  tube  will  indicate 
the  percentage  of  hemoglobin. 

FleischVs  msiruirieiit  consists  of  a  metal  stand  with  a  cir- 
cular aperture  in  the  center,  under  which  is  placed  a  re- 
flector made  of  plaster-of- Paris.  The  aperture  is  fitted  with 
a  small  cell  having  a  glass  bottom,  and  divided  into  two 
equal  compartments.  A  graduated  wedge  of  colored  glass 
is  employed  as  a  standard,  the  100  on  the  scale  being  in- 
tended to  represent  the  percentage  of  hemoglobin  in  normal 
blood.  This  wedge  of  glass  is  so  arranged  that  when 
moved  under  the  stand,  one  compartment  of  the  cell  will 
receive  white  light  from  the  reflector,  and  the  other,  red 
light  from  the  tinted  glass.  A  small  capillary  tube  is  held 
over  a  drop  of  blood  until  filled,  and  is  then  washed  in  one 
of  the  compartments  of  the  cell,  in  which  has  been  pre- 
viously placed  some  distilled  water.  Both  compartments 
are  then  equally  filled  with  water,  and  the  wedge  of  glass  is 
moved  by  means  of  a  thumb-screw  until  the  tints  in  the  two 
chambers  are  exactly  the  same,  when  the  percentage  of 
hemoglobin  may  be  read  off. 

In  the  examination  it  is  necessary  to  use  artificial  Hght. 
The  100  mark  on  the  scale,  which  is  intended  to  represent 
the  percentage  of  hemoglobin  in  normal  blood,  is  too  high 
for  the  average  person,  85  or  90  per  cent,  rarely  being  ex- 
ceeded. 

The  Specific  Gravity  of  the  Blood.— The  specific 


EXAMINATION  OF   THE  BLOOD.  1 47 

gravity  of  the  blood  in  health  varies  from  1050  to  1070.  In 
grave  anemia  it  is  often  considerably  diminished.  Ham- 
merschlag's  method  consists  in  expelling  a  drop  of  blood 
into  a  mixture  of  chloroform  and  benzol,  one  or  the  other 
of  these  substances  being  subsequently  added  until  the  drop 
neither  rises  nor  falls.  The  specific  gravity  of  the  mixture 
may  then  be  ascertained  in  the  usual  way.  Lloyd  Jones 
employs  mixtures  of  glycerin  and  water  of  different  densi- 
ties, and  notes  the  specific  gravity  of  the  mixture  in  which 
the  blood-drop  remains  stationary. 

Alkalinity  of  the  Blood. — The  alkahnity  of  the  blood 
may  be  determined  by  titrating  with  a  standard  solution  of 
acetic  acid  until  a  change  of  color  is  produced  when  a  drop 
is  placed  on  a  plaster-of-Paris  plate  impregnated  with  neutral 
litmus. 

^numeration  of  Red  Blood- corpuscles. — The  best 
instrument  for  blood  counting  is  the  hemocytometer  of 
Thoma-Zeiss.  This  consists  of  a  glass  slide  in  the  center 
of  which  is  a  cell  ^  mm.  in  depth.  The  floor  of  the  cell  is 
divided  into  400  small  squares,  each  of  which  has  an  area 
of  ^-Q  square  millimeter.  These  small  squares  are  grouped 
into  sets  of  16  by  a  series  of  additional  vertical  and  hori- 
zontal lines  bisecting  each  fifth  column  of  squares.  As  the 
depth  of  the  cell  from  the  cover-glass  is  -^  mm.,  the  cubic 
contents  of  each  small  square  is  4^Vo  ^'^^■ 

The  blood  is  mixed  in  a  melangeiir — that  is,  a  capillary 
tube  one  extremity  of  which  is  blown  into  a  bulb  having  a 
capacity  of  100  cm.  The  melangeur  is  marked  at  0.5,  i, 
and  10 1.  A  drop  of  blood  issuing  from  a  prick  of  the 
finger  is  sucked  cautiously  into  the  tube  exactly  to  the 
mark  0.5.  The  point  of  the  tube  is  quickly  wiped  dry  and 
immersed  in  the  diluting  fluid  (2.5  per  cent,  solution  of 
potassium  bichromate  or  Toison's  fluid  ^),  which  is  drawn 
up  to  the  10 1  mark.  The  instrument  is  now  shaken  to 
secure  diffusion  of  the  blood.  The  diluting  fluid  remaining 
in  the  stem  of  the  melangeur  is  now  blown  out,  and  a  drop 
of  the  mixture  placed  upon  the  middle  of  the  bottom  of  the 

1  Methyl-violet,  5   B,  0.025  gm. ;   sodium  chlorid,  I  gm. ;   pure  sodium  sul- 
phate, 8  gm. ;  neutral  glycerin,  30  c.c. ;  distilled  water,  160  c.c. 


148    DISEASES   OF  BLOOD  AND  DUCTLESS   GLANDS. 

divided  cell.  The  drop  in  the  cell  should  be  free  from  bub- 
bles, and  the  cover-glass  so  adjusted  that  concentric  rings 
of  color  appear  at  the  points  of  contact  between  the  cover- 
glass  and  the  glass  plate.  Before  counting,  a  few  minutes 
should  be  allowed  for  the  corpuscles  to  settle  to  the  bottom 
of  the  cell.  The  number  of  corpuscles  is  then  counted  in 
400  small  squares.  To  avoid  repetition  in  counting,  cor- 
puscles on  the  upper  and  left  boundary-lines  should  be 
counted,  but  those  on  the  lower  and  right  boundary-hnes 
should  be  disregarded.  The  number  of  corpuscles  in  each 
cubic  miUimeter  of  blood  is  determined  by  multiplying  the 
number  of  corpuscles  counted  by  the  degree  of  dilution 
(200)  and  again  by  the  cubic  contents  of  each  square  (4000), 
and  then  dividing  the  product  by  the  number  of  squares 
counted  (400).  Thus,  if  2000  corpuscles  were  counted  in 
400  squares,  the  number  of  corpuscles  in  each  cubic  milli- 
meter would  be  4,000,000  — 

2000  X  200  X  4000 

=  4,000,000. 


400 

After  using,  the  melangeur  should  be  carefully  washed  in 
water,  alcohol,  and  ether. 
i^numeration    of   White    Blood- corpuscles. — For 

counting  the  white  blood-cells  a  melangeur  should  be  used 
which  allows  a  dilution  in  the  proportion  of  i  :  10  and  an 
aqueous  0.5  per  cent,  solution  of  acetic  acid,  to  which  may 
be  added  a  little  methyl-violet,  should  be  selected  as 
a  diluting  fluid.  The  red  cells  disappear  in  this  solution, 
and  the  white  cells  remain  and  are  readily  counted.  The 
latter  should  be  counted  in  800  small  squares.  The  num- 
ber of  leukocytes  in  each  cubic  millimeter  is  then  determined 
by  multiplying  the  whole  number  counted  by  4000,  and 
again  by  10,  and  dividing  by  800. 

The  Study  of  the  White  Blood-corpuscles.— In 
normal  blood  the  following  forms  of  leukocytes  may  be 
recognized. 

I.  Small  Lymphocytes. — These  are  small  cells  about  the 
size  of  the  red  blood-corpuscles.  The  nucleus  is  very  large 
and  spheric,  and  stains  intensely  with  basic  stains  (methylene- 


EXAMINATION  OF   THE   BIO  OB.  1 49 

blue).  With  Ehrlich's  triacid  mixture  the  nucleus  is  pale. 
The  narrow  rim  of  protoplasm  surrounding  the  nucleus  is 
non-granular  (hyahne).  Small  lymphocytes  constitute  from 
25  to  35  per  cent,  of  all  leukocytes. 

2.  Large  Lymphocytes. — These  cells  resemble  those  just 
described,  but  they  are  considerably  larger.  The  nucleus 
is  relatively  not  so  large,  and  stains  less  deeply.  In  some 
form  the  nucleus  is  more  or  less  bent  or  indented  (transi- 
tional leukocytes).  Normally,  large  lymphocytes  make  up 
from  5  to  10  per  cent,  of  the  blood-corpuscles. 

Polymorphonuclear  Neutrophiles. — These  cells  are  some- 
what smaller  than  large  lymphocytes,  and  are  actively  ame- 
boid. The  nucleus  appears  to  be  divided  into  two  or  more 
segments  and  stains  deeply.  The  protoplasm  is  studded 
with  fine  granules,  which  do  not  stain  well  with  either  simple 
basic  stains  (methylene-blue)  or  simple  acid  stains  (eosin). 
With  Ehrlich's  triacid  mixture  the  granules  are  colored 
violet  and  the  protoplasm  pale  pink.  Neutrophiles  make 
up  from  60  to  70  per  cent,  of  the  white  cells  of  normal 
blood. 

Eosinophiles. — These  resemble  the  polymorphonuclear 
neutrophiles,  but  are  more  irregular  in  outline,  and  the 
granules  are  larger,  more  highly  refractive,  more  loosely 
attached,  and  have  a  special  affinity  for  acid  stains  (eosin). 
Eosinophiles  make  up  from  i  to  4  per  cent,  of  the  leukocytes. 

Mast-cells  (Basophiles). — These  cells  have  a  lobulated 
nucleus.  The  protoplasm  is  studded  with  granules  having 
an  intensely  basic  reaction.  These  granules  remain  un- 
stained with  Ehrlich's  triacid  mixture,  but  with  methylene- 
blue  they  stain  deep  blue.  Mast-cells  are  only  occasionally 
encountered  in  normal  blood. 

In  disease,  additional  forms  are  sometimes  found.  Thus 
in  leukemia  large  cells  are  found  which  are  non-ameboid 
and  which  have  a  single  round  or  oval  nucleus  imbedded  in 
protoplasm  containing  neutrophilic  granules.  These  have 
been  termed  myelocytes. 

With  the  aid  of  a  one-twelfth  inch  oil-immersion  lens 
large  and  small  leukocytes  can  readily  be  distinguished  in 
preparations  of  fresh  blood,  but  to  study  satisfactorily  the 


150    DISEASES   OF  BLOOD  AND  DUCTLESS   GLANDS. 

various  forms  it  is  necessary  to  dry  and  then  stain  the  speci- 
men. 

The  Drying  and  Staining:  of  Blood. — A  small  drop 
of  blood,  secured  by  pricking  the  finger,  is  spread  into  a 
film  by  being  pressed  between  two  perfectly  clean  cover- 
glasses,  which  are  then  drawn  apart  and  exposed  to  the  air 
until  dry.  The  cover-glasses  should  be  handled  with  for- 
ceps, since  the  moisture  of  the  fingers  distorts  the  corpuscles. 
The  preparation  is  first  **  fixed "  by  heating  on  a  copper 
bar  for  from  one-half  to  one  hour  at  a  temperature  of  from 


»•  #  ^  •», 

Fig.  7. — Blood  in  lienomedullary  leukemia,  showing  several  mononuclear 
neutrophiles  (myelocytes),  one  polymorphonuclear  neutrophile,  and  an  eosino- 
phile ;  a  nucleated  red  corpuscle  and  a  lymphocyte  are  seen  in  the  lower  part 
of  the  illustration.  Stained  with  Ehrlich's  triple  mixture  (from  Stengel's  Tex^- 
Book  of  Pathology). 

100°  to  110°  C,  or  by  immersing  for  from  five  to  fifteen 
minutes  in  a  mixture  of  equal  parts  of  absolute  alcohol  and 
ether. 

A  convenient  method  of  staining  is  the  one  suggested  by 
Stengel.  The  fixed  preparation  is  immersed  for  a  few 
minutes  in  a  i  per  cent,  solution  of  eosin  in  60  per  cent, 
alcohol,  to  which  has  been  added  an  equal  quantity  of 
water  at  the  time  of  staining.  The  cover-glass  is  then 
washed  in  water  and  counterstained  in  Delafield's  hema- 
toxylin for  a  minute,  and  finally  washed,  dried,  and  mounted. 
The  eosinophile  granules  are  dark   red,  the  red  corpuscles 


PLE  THORA—POL  YC  YTHEMIA.  I  5 1 

lighter  red,  and  the  nuclei  of  the  leukocytes  almost  black. 
Ehrlich's  triacid  mixture  (methyl-green,  Orange  G,  and 
acid-fuchsin)  makes  an  excellent  stain.  The  film  should 
be  fixed  by  heat  and  flooded  with  the  stain.  After  the  lapse 
of  from  five  to  eight  minutes  the  stain  should  be  washed  off 
in  running  water  and  the  film  dried  by  gentle  heat  and 
mounted  in  xylol  balsam.  With  this  stain  the  red  cells  are 
tinged  orange,  the  nuclei  of  the  leukocytes  greenish-blue, 
the  neutrophile  granules  violet,  the  eosinophile  granules  red, 
the  nuclei  of  normoblasts  purple,  and  the  nuclei  of  macro- 
blasts  greenish-blue. 

PLETHORA. 

An  increase  in  the  whole  quantity  of  blood.  It  is  very 
doubtful  whether  such  a  condition  can  be  more  than  tran- 
sitory. 

HYDREMIA. 

An  excess  of  water  in  the  blood.  As  a  loss  of  corpuscular 
elements  is  generally  replaced  by  the  addition  of  water 
extracted  from  the  tissues,  most  anemias  are  associated  with 
hydremia.  The  condition  is  more  marked  in  general  dropsy. 
Temporary  hydremia  is  produced  by  the  excessive  ingestion 
of  fluids. 

ANHYDREMIA. 

A  deficiency  of  fluid  in  the  blood.  It  is  observed  in 
starvation,  immediately  after  hemorrhage,  and  after  copious 
discharges,  as  in  cholera. 

MELANEMIA. 

A  condition  in  which  free  pigment  granules  occur  in  the 
blood.  It  is  met  with  in  malaria  and  certain  other  fevers, 
and  occasionally  in  melanosarcoma  and  in  Addison's  dis- 
ease. The  pigment  may  be  found  in  the  plasma  or  in  the 
leukocytes. 

POLYCYTHEMIA. 

Polycythemia,  or  an  increase  in  the  number  of  red  cells, 
is  an  apparent    condition    in    blood  taken    from    cyanosed 


152    DISEASES   OF  BLOOD  AND  DUCTLESS   GLANDS. 

parts.  It  is  observed  temporarily  in  the  new-born,  in  re- 
covery from  certain  anemias,  after  transfusion  of  blood,  and 
in  blood  concentrated  by  excessive  discharges.  Marked 
polycythemia  is  sometimes  produced  by  residence  in  high 
altitudes  and  by  certain  poisons,  such  as  phosphorus  and 
carbon  monoxid.  It  also  occurs  in  the  condition  known  as 
chronic  splenomegalic  polycythemia. 

MICROCYTOSIS  AND  MACROCYTOSIS. 

Microcytosis  and  macrocytosis  are  conditions  in  which 
the  red  cells  are  respectively  diminished  and  increased  in 
size.  They  may  occur  in  any  form  of  severe  anemia,  but 
they  are  especially  marked  in  pernicious  anemia. 

POIKILOCYTOSIS. 

Poikilocytosis,  a  condition  in  which  the  red  cells  are 
irregular  in  shape,  is  common  in  grave  anemias,  especially 
pernicious  anemia. 

NUCLEATED  RED  CELLS. 

Nucleated  red  cells  (erythroblasts)  are  divided  into  three 
forms — normoblasts,  macroblasts,  and  microblasts.  The 
first  resemble  in  size  and  color  a  normal  red  cell,  the  sec- 
ond are  larger,  and  the  third  smaller.  Nucleated  red  cells 
are  not  found  normally  in  the  circulating  blood ;  they  are 
present,  however,  in  grave  forms  of  anemia. 

LEUKOCYTOSIS. 

Leukocytosis,  or  hyperleukocytosis,  is  an  increase  in  the 
number  of  white  cells,  especially  of  the  polymorphonuclear 
forms,  in  the  peripheral  blood.  It  occurs  physiologically 
in  the  new-born,  during  digestion,  in  pregnancy,  parturition, 
and  after  heavy  exertion,  cold  bathing,  and  massage. 

Pathologic  leukocytosis  is  observed  in  the  following  con- 
ditions :  (i)  Inflammation.  There  is  an  absolute  increase  in 
the  polymorphonuclear  neutrophiles.  (2)  Infectious  diseases. 
Most  infections  excite  leukocytosis,  but  the  condition  is 
usually  wanting  in  typhoid  fever,  malaria,  measles,  influenza, 
and  miliary  tuberculosis.     In  any  infection  in  which  the  tox- 


EOSINOPHILIA—OLIGOCHROiMEMIA.  1 53 

emia  is  intense  or  the  resistance  of  the  individual  is  sHght, 
leukocytosis  may  be  wanting.  (3)  Malignant  disease,  when 
sufficiently  extensive.  (4)  After  hemorrhage.  (5)  After  the 
administration  of  certain  drugs,  such  as  pilocarpin,  anti- 
pyrin,  salicylates,  ergotin,  and  tuberculin.  (6)  In  certain 
autointoxications,  such  as  gout  and  uremia. 

EOSINOPHILIA. 

A  relative  or  absolute  increase  of  the  eosinophiles  occurs 
in  certain  diseases  caused  by  animal  parasites,  such  as 
trichiniasis,  filariasis,  and  ankylostomiasis ;  in  bronchial 
asthma,  in  osteomalacia,  and  in  certain  skin  diseases,  notably 
in  pemphigus,  eczema,  psoriasis,  and  dermatitis  herpetiformis. 

LEUKOPENIA,  OR  HYPOLEUKOCYTOSIS. 

Leukopenia,  or  hypoleukocytosis,  is  the  name  applied  to 
a  deficiency  in  the  number  of  leukocytes.  It  occurs  in 
certain  infections,  particularly  in  those  that  do  not  produce 
leukocytosis,  such  as  typhoid  fever,  malaria,  and  miliary 
tuberculosis ;  also  in  pernicious  anemia  and  inanition. 

LIPEMIA, 

Lipemia,  the  presence  in  the  blood  of  minute  fat-globules, 
may  be  noted  in  health.  Abnormal  quantities  of  fat  may 
be  found  in  the  blood  in  diabetes,  chronic  nephritis,  alcohol- 
ism, and  pulmonary  tuberculosis. 

PARASITES  IN  THE  BLOOD, 

The  following  parasites  have  been  detected  in  the  blood  : 
Filaria  sanguinis  hominis,  hematozoan  of  malaria,  spirillum 
of  relapsing  fever,  pneumococcus,  bacillus  of  anthrax,  typhoid 
fever,  tetanus,  tuberculosis,  influenza,  leprosy,  glanders, 
bubonic  plague,  malignant  edema,  and  diphtheria  ;  the  strep- 
tococcus, staphylococcus,  meningococcus,  gonococcus,  try- 
panosoma,  and  colon  bacillus. 

OLIGOCHROMEMIA. 

Oligochromemia,  or  deficiency  of  hemoglobin,  is  usually 
proportionate  to  the  reduction  in  the  number  of  red  cells, 


154    DISEASES   OF  BLOOD  AND  DUCTLESS   GLANDS. 

but  there  are  two  exceptions,  namely,  in  chlorosis,  in  which 
disease  the  red  cells  may  be  reduced  only  20  or  30  per 
cent.,  while  the  hemoglobin  may  be  reduced  50  or  60  per 
cent.,  and  in  pernicious  anemia,  in  which  disease  the  blood- 
count  is  very  low,  while  the  corpuscles  are  relatively  rich  in 
hemoglobin. 

The  color-index  represents  the  relation  between  the  num- 
ber of  cells  and  the  quantity  of  hemoglobin.  In  a  patient 
having  2,500,000  red  cells  per  cubic  millimeter  (50  per  cent.) 
and  40  per  cent,  of  hemoglobin,  the  color-index  would  be 
40 

OLIGOCYTHEMIA, 

Oligocythemia,  a  diminution  in  the  number  of  red  cells, 
occurs  in  all  forms  of  anemia,  but  it  is  especially  marked  in 
pernicious  anemia  and  in  advanced  malignant  disease,  where 
the  number  may  fall  below  1,000,000  in  a  cubic  millimeter. 

ANEMIA. 

Definition. — A  deterioration  of  the  blood,  with  altered 
relations  of  the  fluid  and  soHd  parts  (Stengel). 

Varieties. — (i)  Secondary  anemia;  (2)  primary  anemia. 

Symptoms. — Any  forms  of  anemia  may  present  the  fol- 
lowing symptoms  :  Pallor  of  the  skin  and  mucous  mem- 
branes, loss  of  strength,  and,  in  severe  cases,  febrile  parox- 
ysms. 

Circulation. — A  full,  rapid  pulse,  unnatural  pulsation  of 
the  cervical  vessels,  palpitation  of  the  heart,  a  hemic  mur- 
mur, a  hum  over  the  jugular  vein,  and  slight  dropsy,  be- 
ginning in  the  feet.  In  severe  forms  there  may  be  ecchy- 
moses  and  bleeding  from  mucous  membranes. 

Respiration. — Hurried  breathing. 

Digestion. — Dyspepsia. 

Nervous  System. — Headache,  vertigo,  disturbed  sleep, 
neuralgic  pains,  and  tendency  to  syncope. 


ANEMIA.  155 

SECONDARY  ANEMIA. 

Definition. — A  secondary  anemia  is  one  that  is  symp- 
tomatic of  some  conspicuous  underlying  condition. 

Htiology. — Secondary  anemia  usually  results  from  one 
of  three  causes:  (i)  Insufficient  nutriment  entering  the 
circulation  (inadequate  food,  chronic  gastritis,  cancer  of 
the  pylorus,  etc.).  (2)  Excessive  demands  upon  the  blood- 
making  organs  (overwork,  hemorrhage,  chronic  diarrhea, 
etc.).  (3)  Action  of  parasites  or  toxic  agents  (malaria,  lead, 
syphilis,  uremia,  etc.). 

The  anemia  produced  by  the  presence  in  the  bowel  of 
the  Ankylostomum  duodenale  and  Bothriocephalus  latus 
may  be  due  to  poisons  generated  by  these  parasites. 

Symptoms. — In  addition  to  the  ordinary  phenomena  of 
anemia  the  blood-count  reveals  a  decrease  in  the  number 
of  red  cells  and  a  proportionate  deficiency  in  the  percentage 
of  hemoglobin.  The  number  of  polymorphonuclear  leuko- 
cytes is  often  increased.  In  severe  form,  microcytes,  macro- 
cytes,  and  poikilocytes  are  present,  and  occasionally  nu- 
cleated red  cells. 

Prognosis. — This  depends  on  the  cause. 

Treatment. — This  includes  the  removal  of  the  cause, 
when  possible  ;  the  adoption  of  hygienic  measures ;  and  the 
use  of  iron,  arsenic,  and  general  tonics. 

PRIMARY  ANEMIA. 

Definition. — A  primary  anemia  is  one  that,  in  the  pres- 
ent state  of  our  knowledge,  cannot  be  associated  with  any 
conspicuous  underlying  cause. 

Varieties. — Pernicious  anemia,  chlorosis,  leukemia, 
Hodgkin's  disease,  and  splenic  anemia. 

PERNICIOUS  ANEMIA. 
(Progressive  Pernicious  Anemia.) 

Definition. — A  grave  form  of  anemia  characterized  by 
extreme  oligocythemia,  marked  changes  in  the  red  blood- 


156    DISEASES   OF  BLOOD   AND   DUCTLESS   GLANDS. 

corpuscles,  and  a  decrease  in  the  number  of  the  polymor- 
phonuclear neutrophiles. 

!]^tiology. — In  many  cases  no  adequate  cause  is  appar- 
ent.  The  disease  usually  appears  about  middle  life,  and  is 
somewhat  more  frequent  in  males  than  in  females.  Forms 
of  anemia  closely  resembling  pernicious  anemia  may  result 
from  the  action  of  intestinal  parasites,  especially  the  Both- 
riocephalus  latus  and  the  Ankylostoma  duodenale.  The 
most  plausible  theory  is  that  the  disease  is  due  to  the 
hemolytic  action  of  some  poison  absorbed  from  the  gastro- 
intestinal tract. 

Patholog"y. — The  skin  has  a  lemon-yellow  hue,  the  sub- 
cutaneous fat  is  often  well  preserved,  and  the  muscles  are 
unusually  red.  The  organs  are  pigmented  and  fatty.  Iron 
pigment  is  especially  abundant  in  the  outer  zones  of  the 
hepatic  lobules.  Marked  atrophy  of  the  gastric  mucosa  is 
sometimes  observed.  The  bone-marrow  is  dark  red,  soft, 
and  contains  large  numbers  of  nucleated  red  cells,  especially 
macroblasts.  The  hemolymph  glands  are  frequently  en- 
larged, congested,  and  pigmented.  The  spleen  is  some- 
times enlarged.  In  many  cases  there  is  found  advanced 
sclerosis  of  the  posterior  and  lateral  columns  of  the  spinal 
cord. 

Symptoms. — The  general  symptoms  are  intense  anemia, 
with  its  usual  manifestations ;  a  lemon-yellow  tint  to  the 
skin ;  progressive  weakness,  without  marked  emaciation ; 
moderate,  irregular  fever ;  severe  gastric  irritability ;  and 
sometimes  dark-colored  urine  from  the  presence  of  urobilin. 

The  Blood. — The  drop  is  pale  and  watery.  Coagulation 
is  slow.  There  is  a  great  reduction  in  the  number  of  red 
cells,  often  to  1,000,000  or  less;  the  hemoglobin  is  also  re- 
duced, but  not  proportionately.  The  red  cells  usually  show 
decided  changes  both  in  size  and  in  shape.  Nucleated  red 
cells  are  more  or  less  abundant.  As  a  rule,  the  large  forms 
(megaloblasts)  predominate.  The  leukocytes  are  usually 
decreased,  though  the  lymphocytes  are  relatively  increased. 

Diagnosis. — The  parasitic  form  may  be  recognized  by 
the  occurrence  of  eosinophilia  and  the  discovery  of  the 
parasites  or  their  ova  in  the  stools. 


CHLOROSIS.  157 

Cancer  rarely  produces  such  extreme  oligocythemia,  the 
color-index  is  not  high,  macroblasts  are  rarely  present,  and 
there  is  often  leukocytosis. 

Prognosis. — Pernicious  anemia  usually  ends  fatally 
within  one  or  two  years.  It  is  doubtful  whether  recovery 
ever  occurs  except  in  the  parasitic  forms.  Periods  of 
marked  improvement  are  not  uncommon. 

Treatment. — Fresh  air,  rest,  and  a  diet  as  liberal  as  the 
digestive  power  of  the  patient  will  permit  are  requisite. 
Warm  salt  baths  and  massage  are  valuable  adjuvants  to 
internal  treatment.  The  teeth  should  receive  careful  atten- 
tion. If  there  be  gingivitis  or  pyorrhoea  alveolaris,  antiseptic 
mouth-washes  should  be  used  at  frequent  intervals. 

Arsenic  is  the  most  valuable  drug.  It  may  be  given  in 
the  form  of  Fowler's  solution,  the  dose  being  gradually 
increased  from  2  or  3  to  15  or  20  minims  three  times 
a  day.  Iron  is  rarely  of  service.  Bone-marrow  is  some- 
times efficacious.  Inhalations  of  oxygen  have  been  recom- 
mended (Shattuck).  Appropriate  anthelmintic  remedies 
should  be  given,  of  course,  in  the  cases  in  which  intestinal 
parasites  are  present.  Digestive  disturbances  are  often 
benefited  by  the  administration  of  diluted  hydrochloric  acid 
and  a  bitter. 

CHLOROSIS* 

(Greensickness;  Primary  Anemia.) 

Definition. — A  form  of  anemia  occurring  exclusively  in 
young  women  and  characterized  by  marked  oHgochromemia. 

Ktiology. — The  disease  usually  occurs  between  the 
fifteenth  and  twenty-fifth  years.  Heredity,  bad  hygienic 
surroundings,  and  overwork  are  predisposing  factors.  The 
real  cause  of  the  disease  has  not  been  determined. 

Pathology. — In  some  fatal  cases  imperfect  development 
of  the  vascular  and  generative  systems  has  been  observed. 

Symptoms. — In  addition  to  the  general  symptoms  of 
anemia  the  conspicuous  features  are  a  greenish  hue  of  the 
skin  ;  pallor  and  weakness  without  marked  loss  of  flesh  ;  per- 
versions of  appetite  (pica);  menstrual  disorders;  and  a  ten- 
dency to  hysteric  outbreaks.     The  blood  changes  are  char- 


158    DISEASES   OF  BLOOD  AND  DUCTLESS   GLANDS. 

acteristic.  The  number  of  red  cells  is  moderately  reduced 
(not  often  below  3,500,000) ;  the  hemoglobin,  on  the  other 
hand,  is  greatly  reduced — usually  to  below  50  per  cent. 
There  is  no  leukocytosis. 

Cotnplications. — Gastroptosis,  peptic  ulcer,  gastralgia, 
amenorrhea,  and,  occasionally,  thrombosis  of  the  cerebral 
sinuses  or  veins  of  the  extremities. 

Prognosis. — The  prognosis  is  good,  but  relapses  are 
common. 

Treatment. — Fresh  air,  sunhght,  open-air  exercise,  and 
nourishing  food  are  valuable  aids  in  treatment.  Very  severe 
cases  require  complete  rest  in  bed.  If  there  be  a  good  reac- 
tion, warm  baths,  followed  by  short  cold  douches,  are  effica- 
cious. Iron  is  almost  a  specific.  It  is  most  frequently  pre- 
scribed in  the  form  of  Blaud's  pills,  of  which  the  dose  is 
three  pills,  gradually  increased  to  nine,  a  day. 

Laxatives,  preferably  mild  salines,  rank  next  in  impor- 
tance to  iron.  Arsenic  is  distinctly  less  valuable  than 
iron.  Superacidity  of  the  gastric  juice  is  best  treated  by 
alkahs. 

LEUKEMIA* 

(Leukocythemia.) 

Definition. — A  disease  characterized  by  a  persistent  in- 
crease in  the  number  of  white  blood-corpuscles  and  by 
pathologic  changes  in  the  bone-marrow,  spleen,  and  lymph- 
atic glands. 

l^tiology. — The  causes  are  obscure.  More  males  are 
affected  than  females.  The  disease  occurs  most  frequently 
in  middle  life.  Heredity,  malaria,  syphilis,  pregnancy,  and 
traumatism  are  given  as  predisposing  factors.  An  infectious 
origin  has  been  suggested. 

Varieties. — (i)  Myelogenous  leukemia  and  (2)  lymph- 
atic leukemia.     The  latter  may  be  acute  or  chronic. 

Pathology. — There  is  extreme  emaciation.  In  the  mye- 
logenous form  the  fat  of  the  bone-marrow  is  largely  re- 
placed by  marrow-cells,  both  red  and  white,  and,  according 
as  the  one  or  the  other  predominates,  the  marrov/  presents 
a  currant-jelly  or  pyoid  appearance.     All  the  cells  of  the 


LEUKEMIA.  159 

marrow  are  increased,  but  the  myelocytes  are  in  excess. 
The  spleen  and  liver  are  much  enlarged :  the  former  from 
a  hyperplasia  of  the  lymphoid  structures,  the  latter  from 
infiltration  of  leukocytes.  In  lymphatic  leukejuia  the  char- 
acteristic feature  is  enlargement  of  the  visible  lymph-glands. 
Microscopically,  the  glands  show  a  great  increase  of  lympho- 
cytes. Numerous  metastatic  lymphomas  are  found  in  the 
various  organs.  The  bone-marrow,  spleen,  and  liver  are 
also  more  or  less  involved. 

Symptoms. — Myelogenous  leukemia  presents  the  general 
symptoms  of  anemia.  The  liver  and  spleen  are  consider- 
ably enlarged.  There  may  be  moderate  fever  of  an  irregu- 
lar type.  Hemorrhages  from  mucous  membranes  and  into 
the  tissues  are  common.  Impairment  of  vision  may  result 
from  retinal  hemorrhage  or  leukemic  infiltration.  Persistent 
priapism  is  occasionally  observed. 

The  blood  changes  are  characteristic.  There  is  a  grad- 
ual reduction  in  the  number  of  red  cells  and  of  hemo- 
globin. The  number  of  white  cells  is  enormously  increased, 
the  count  often  reaching  from  300,000  to  500,000.  From 
20  to  60  per  cent,  of  the  leukocytes  are  myelocytes.  The 
number  of  eosinophiles  and  mast-cells  is  somewhat  in- 
creased. 

Lymphatic  leuke^nia  is  rare.  The  chronic  form  presents 
the  general  symptoms  of  anemia,  with  enlargement  of  the 
visible  lymph-glands  and  a  considerable  increase  in  the 
number  of  leukocytes  (50,000  to  100,000),  more  than  90 
per  cent,  of  which  are  small  lymphocytes. 

Acute  lymphatic  leukemia  has  been  most  frequently  seen 
in  children.  The  visible  lymph-glands  are  enlarged,  there 
is  marked  tendency  to  hemorrhages,  and  the  blood  con- 
tains great  numbers  of  large  pale  lymphocytes. 

Diagnosis. — Leukocytosis. — In  this  condition  the  white 
cells  are  not  so  enormously  increased  and  are  chiefly  poly- 
morphonuclear neutrophiles. 

Malarial  Cachexia. — This  may  be  recognized  by  the  dis- 
covery of  the  parasites  and  by  the  absence  of  leukocytosis. 

Prognosis. — Absolutely  unfavorable.  The  average  du- 
ration of  the  chronic  form  is  from  two  to  three  years.  Acute 
leukemia  may  prove  fatal  within  a  few  weeks. 


l6o  DISEASES   OF  BLOOD   AND  DUCTLESS   GLANDS. 

Treatment. — An  effort  should  be  made  to  maintain  the 
general  nutrition  by  regulating  the  diet  and  attending  to 
hygienic  measures.  Rest  is  often  advisable.  Among  drugs, 
arsenic  appears  to  be  of  some  service.  The  use  of  the 
.f-rays  is  often  followed  by  marked,  though  temporary,  im- 
provement.    Operative  treatment  is  of  no  avail. 

HODGKIN'S  DISEASE. 

(Pseudoleukemia ;  General  Lymphadenoma ;  Adenia ;  Lymphatic 

Anemia.) 

Definition. — A  rare  disease  characterized  by  hyper- 
plasia of  the  lymphatic  glands  and  progressive  anemia, 
without  a  marked  excess  of  white  corpuscles. 

^^tiology. — The  causes  are  unknown.  It  is  most  com- 
monly seen  in  young  adults  of  the  male  sex.  In  some  in- 
stances it  has  appa-fently  followed  an  ordinary  adenitis.  An 
infectious  origin  has  been  suggested. 

Pathology. — There  is  a  marked  hyperplasia  of  the  lym- 
phatic glands, — cervical,  axillary,  mediastinal,  inguinal,  and 
retroperitoneal, — the  spleen  and  bone-marrow  often  sharing 
in  the  process. 

Symptoms. — The  disease  resembles  lymphatic  leukemia, 
but  there  is  an  absence  of  leukocytosis.  The  glands  of  the 
neck  are  usually  first  affected ;  the  swellings  are  painless, 
freely  movable.,  and  only  very  rarely  suppurate. 

Diagnosis. — Tuberculous  adenitis  is  more  apt  to  affect 
the  submaxillary  glands,  and  is  often  unilateral.  Fusion  of 
the  glands  and  suppuration  are  common.  The  tuberculin 
reaction  may  be  obtained,  and  section  of  an  excised  gland 
shows  tuberculous  elements. 

Prognosis. — Unfavorable.  The  average  duration  is 
from  two  to  three  years.     Treatment  is  that  of  leukemia. 

SPLENIC  ANEMIA. 
(Splenomegaly.) 
Splenic  anemia  is  a  chronic  affection  characterized  by  an 
enormous  enlargement  of  the  spleen,  moderate  oligocy- 
themia (average  count  3,400,000),  decided  oligochromemia 
(average  45  to  50  per  cent.),  leukopenia,  and  a  marked  ten- 
dency to  hemorrhage,  especially  from  the  stomach.     In  the 


ADDISON'S  DISEASE.  l6l 

terminal  stage  there,  may  be,  in  addition,  ascites,  jaundice, 
and  cirrhosis  of  the  liver  {Banti's  disease).  Splenic  anemia 
usually  lasts  for  many  years.  In  7  of  i8  cases  studied  by 
Osier  the  duration  of  the  dise;i3e  was  more  than  ten  years, 
and  in  1 1  more  than  four  years.  Of  32  cases  of  splenic 
anemia  treated  by  splenectomy,  in  23  recovery  followed 
(Armstrong). 

CHRONIC  SPLENOMEGALIC  POLYCYTHEMIA. 

Chronic  splenomegalic  polycythemia  is  a  rare  affection 
having  general  redness  or  cyanosis  of  the  skin,  polycy- 
themia (8-13  millions  per  cmm.),  high  blood-pressure,  and 
enlargement  of  the  spleen  for  its  chief  symptoms.  Later, 
asthenia,  dyspnea,  edema,  dilatation  of  the  heart,  and  albu- 
minuria occur  and  may  be  associated  with  drowsiness  and 
mental  depression.  The  course  extends  over  many  years, 
but  the  tendency  is  to  terminate  ultimately  by  heart  failure 
or  apoplexy. 

According  to  one  theory,  the  disease  depends  upon  an  over- 
production of  the  red  cells  in  the  bone  marrow,  which  some- 
times shows  evidence  of  proliferation  ;  according  to  another 
theory,  it  is  the  result  of  vasoconstriction  of  nervous  origin. 

ADDISON'S  DISEASE. 

I>efillitioil. — A  rare  disease  characterized  anatomically 
by  lesions  of  the  suprarenal  glands  or  of  the  abdominal 
sympathetic  ganglia,  and  clinically  by  bronzing  of  the  skin 
and  profound  asthenia. 

!^tiology. — It  occurs  most  frequently  in  middle  life,  and 
is  more  common  in  men  than  in  women.  The  development 
of  Addison's  disease  is  favored  by  the  predisposing  causes 
of  tuberculosis. 

Pathology. — In  most  instances  tuberculosis  of  the 
suprarenal  bodies  is  discovered.  Rarely  other  lesions  of 
the  suprarenal  bodies,  such  as  carcinoma,  have  been  found. 
In  a  few  cases  there  have  been  found  degenerative  changes 
in  the  abdominal  sympathetic  gangHa,  either  in  connection 
with,  or  in  the  absence  of,  disease  of  the  suprarenal  bodies. 

Symptoms. — The  chief  features  are  moderate  anemia, 
bronzing  of  the  skin,  pigmentation   of  the  mucous  mem- 


1 62   DISEASES   OF  BLOOD  AND  DUCTLESS   GLANDS. 

branes,  especially  of  the  mouth,  extreme  weakness,  and 
marked  gastric  irritability. 

Prognosis. — The  disease  is  fatal.  The  average  duration 
is  from  one  to  three  years. 

Treatment. — The  general  treatment  includes  rest,  a 
nutritious  but  easily  assimilable  diet,  and  the  administra- 
tion of  tonics.  Temporary  good  effects  have  followed  the 
use  of  the  extract  of  suprarenal  gland  in  doses  of  from  3 
to  5  grains  thrice  daily. 

EXOPHTHALMIC  GOITER. 

(Graves's  Disease;  Parry's  Disease ;  Basedow's  Disease.) 

Definition. — A  disease  characterized  by  enlargement  of 
the  thyroid  gland,  marked  prominence  of  the  eyeballs, 
tachycardia,  and  muscular  tremors. 

]^tiolog"y. — The  disease  most  frequently  develops  in  the 
third  decade.  Women  are  much  more  often  affected  than 
men.  Heredity,  emotional  excitement,  and  mental  strain 
are  predisposing  factors. 

Pathology. — The  pathogenesis  of  Graves's  disease  is 
still  undetermined.  The  disease  is  probably  due  to  excessive 
functional  activity  of  the  thyroid  gland  (hyperthyroidization). 
Greenfield  found  the  tubular  spaces  of  the  gland  proliferated 
and  the  colloid  matrix  replaced  by  a  mucoid  material. 

Symptoms. — Cardiac  Phenomena. — Acceleration  of  the 
pulse  (100  to  150)  and  palpitation  are  constant*  features. 
Both  are  intensified  by  excitement.  Hypertrophy  of  the 
heart  may  ultimately  ensue  from  overaction.  A  soft  sys- 
tolic murmur  is  frequently  heard  at  the  apex. 

Ocular  Phenomena. — These  consist  in  bilateral  protrusion 
of  the  eyeballs,  a  failure  of  the  upper  eyelid  to  follow  the 
eyeball  when  the  latter  is  directed  downward  (Graefe's 
sign),  widening  of  the  palpebral  angle  (Stellwag's  sign), 
and  inability  of  the  eyes  to  converge  upon  a  near  object 
(Mobius'  sign).     Vision  is  not  disturbed. 

Thyroid  Phenomena. — Enlargement  of  the  thyroid  may  be 
the  last  symptom  to  appear.  One  or  both  lobes  of  the  gland 
may  be  affected.  Inspection  detects  enlargement,  with  pulsa- 
tion ;  palpation,  a  purring  thrill ;  and  auscultation,  a  bruit. 

Nervous  Phenomena. — A  fine  muscular  tremor  is  an  early 


MYXEDEMA.  1 63 

symptom.  Nervous  irritability  and  asthenia  are  often  marked. 
Occasionally  mania  or  hypochondriasis  is  observed. 

General  Symptoms. — As  the  disease  progresses  weak- 
ness and  anemia  become  pronounced.  Sweating  is  com- 
mon. Moderate  fever  is  an  occasional  symptom.  There 
may  be  glycosuria  and  albuminuria. 

Diagnosis. — It  should  be  borne  in  mind  that  any  one 
of  the  important  symptoms  may  be  absent  throughout  the 
disease.  In  some  cases  palpitation  and  throbbing  of  the 
cervical  vessels  may  be  the  only  phenomena. 

Goiter  may  be  distinguished  from  exophthalmic  goiter  by 
the  absence  of  cardiac,  ocular,  and  nervous  symptoms. 

Prognosis. — The  disease  generally  runs  a  protracted 
course.  Some  cases  recover  entirely ;  many  improve  and 
subsequently  relapse ;  a  few  die,  after  a  short  illness,  from 
heart  failure  or  acute  mania. 

Treatment. — The  general  nutrition  should  be  improved 
by  rest,  a  generous,  readily  digestible  diet,  healthy  hygienic 
surroundings,  and  hydrotherapy.  In  severe  cases  absolute 
rest  in  bed  is  an  essential  point  in  the  treatment.  Applica- 
tions of  cold,  by  means  of  Leiter's  tubes  or  ice-bags,  to  the 
precordium  lessen  the  palpitation. 

Belladonna  is  undoubtedly  of  value  in  many  cases.  It 
should  be  given  in  ascending  doses  until  some  dryness  of 
the  throat  is  produced.  When  the  circulation  is  feeble, 
digitalis  may  be  found  of  service ;  on  the  other  hand,  when 
the  heart  is  strong,  better  results  may  be  obtained  with 
aconite  or  veratrum  viride.  When  anemia  exists,  iron  is 
useful.  Bromids  are  sometimes  of  service  in  controlling 
nervous  symptoms.  Starr  has  observed  marked  improve- 
ment from  the  use  of  sodium  glycerophosphate  in  doses  of 
20  grains  three  or  four  times  a  day.  The  consensus  of 
opinion  is  decidedly  adverse  to  the   use  of  thyroid  extract. 

Galvanism  sometimes  proves  more  effective  in  controlling 
the  symptoms  than  any  other  remedy.  As  a  last  resort, 
operative  interference  should  be  considered. 

MYXEDEMA. 

Definition. — A    disease    characterized    by   atrophy   of 
the   thyroid   gland,   mucoid    degeneration    of   the   subcu- 


164  DISEASES   OF  BLOOD  AND   DUCTLESS   GLANDS. 

taneous  tissues,  subnormal  temperature,  and  mental  slug- 
gishness. 

etiology. — The  disease  is  much  more  frequent  in  women 
than  in  men.  It  is  occasionally  hereditary.  It  usually 
develops  in  middle  life.  The  immediate  cause  is  the  loss  of 
function  of  the  thyroid  gland. 

A  congenital  form  of  myxedema  is  observed  in  cretinism, 
and  an  analogous  condition  {operative  myxedema  or  cachexia 
strumiprivd)  frequently  follows  total  extirpation  of  the  thy- 
roid gland. 

Symptoms. — It  is  manifested  by  a  gradual  swelling  of 
the  subcutaneous  tissues,  particularly  of  the  face,  supra- 
clavicular regions,  and  hands.  Unlike  edema,  the  parts 
do  not  pit  on  pressure,  but  are  firm  and  elastic.  The 
skin  is  dry  and  harsh.  The  hair  is  dry  and  brittle.  The 
thyroid  gland  is  atrophied.  A  peculiar  slowness  in  thought, 
speech,  and  movements  is  a  characteristic  symptom.  The 
temperature  of  the  body  is  subnormal.  There  is  impair- 
ment of  the  special  senses.  Sensory  phenomena  are  com- 
mon, such  as  coldness,  numbness,  and  tingling.  The  urine 
is  often  increased  in  quantity,  and  occasionally  contains  al- 
bumin, sugar,  and  tube-casts. 

Sequels. — Tuberculosis,  dementia,  and,  occasionally, 
exophthalmic  goiter. 

Diagnosis. — The  mental  dulness,  the  extreme  dryness  of 
the  skin,  and  the  absence  of  pitting  on  pressure  will  serve 
to  distinguish  myxedema  from  Bright's  disease  with  edema. 

Prognosis. — The  disease  was  formerly  considered  incu- 
rable, but  it  is  now  known  that  marked  amelioration  or  even 
a  cure  can  be  effected  by  appropriate  treatment. 

Treatment. — As  patients  with  myxedema  are  extremely 
susceptible  to  low  temperatures,  they  should  be  warmly  clad 
and  protected  from  exposure  to  cold.  Residence  during  the 
winter  in  a  warm,  sunny  climate  is  desirable.  Warm  baths 
are  often  beneficial.  Modern  treatment  consists  in  the  admin- 
istration of  extract  of  sheep's  thyroid  (3  to  5  grains  thrice 
daily).  By  continuing  this  remedy  throughout  life  it  is  pos- 
sible in  many  cases  to  hold  the  symptoms  in  complete 
abeyance. 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


INSPECTION. 

Inspection  determines  the  position,  force,  and  extent  of 
the  apex-beat ;  any  abnormal  centers  of  pulsation  ;  and  any 
unnatural  prominence  over  the  precordial  region. 

The  Apex-beat. — The  normal  position  of  the  apex- 
beat  is  in  the  fifth  intercostal  space,  about  an  inch  within 
the  mid-clavicular  line.  The  beat  can  usually  be  detected 
by  inspection  or  palpation,  but  when  these  methods  fail,  it 
may  be  localized  by  auscultation,  the  point  in  the  region  of 
the  apex  where  the  first  sound  is  heard  with  maximum 
intensity  corresponding  to  the  beat. 

The  Effect  of  Respiration  and  Position  on  the  Apex-beat. — 
The  location  and  force  of  the  apex-beat  are  modified  by 
the  posture  of  the  patient  and  the  stage  of  the  respiratory 
act.  In  the  recumbent  position  the  apex-beat  may  be  ele- 
vated half  an  inch  or  more,  and,  when  the  body  is  inclined 
to  the  left,  the  heart  being  a  more  or  less  movable  organ, 
the  beat  may  be  detected  in  the  mammary  line,  or  even 
some  distance  to  its  outer  side. 

During  forced  inspiration  the  beat  may  become  imper- 
ceptible, or,  if  5uch  is  not  the  case,  it  may  be  found  some 
distance  below  its  usual  place,  on  account  of  the  upward 
movement  of  the  ribs  in  the  inspiratory  act.  During  forced 
expiration  the  air,  being  driven  from  the  Jung-tissue  in  front 
of  the  heart,  the  beat  becomes  more  forcible,  and  its  posi- 
tion elevated  on  account  of  the  descent  of  the  ribs  which 
occurs  in  expiration. 

In  view  of  the  influence  exerted  by  respiration  and  posi- 
tion on  the  apex-beat  the  patient,  as  a  rule,  should  be  ex- 
amined in  the  erect  or  sitting  posture,  while  breathing 
quietly. 

165 


1 66         DISEASES   OF   THE    CIRCULATORY  SYSTEM. 

Displacement  of  the  Apex-beat. — Displacement  to 
the  left  may  result  from  : 

1.  Hypertrophy  or  dilatation  of  the  heart  (down  and  to 
the  left). 

2.  Pericardial  effusion  (up  and  to  the  left). 

3.  Chronic  diseases  of  the  left  lung  and  pleura,  asso- 
ciated with  retraction — as  fibroid  phthisis  and  pleural  adhe- 
sions. 

4.  Abdominal  tumors  and  effusions  (up  and  to  the  left). 

5.  The  pressure  of  a  pleural  effusion  on  the  right  side  (up 
and  to  the  left). 

Displacement  to  the  right  may  be  caused  by : 

1.  Chronic  disease  of  the  right  lung  or  pleura  associated 
with  retraction. 

2.  Pressure  of  a  pleural  effusion  on  the  left  side. 

3.  Transposition  of  the  viscera. 
Displacement  downward  may  result  from  : 

1.  Hypertrophy  or  dilatation  of  the  heart,  chiefly  of  the 
left  ventricle. 

2.  Pressure  of  solid  growths  in  the  upper  mediastinum. 

3.  Aneurysm  of  the  aortic  arch. 

Deformity  of  the  chest  from  spinal  curvature  may  also 
cause  considerable  displacement  of  the  heart. 

Changes  in  Force  and  Extent  of  the  Apex-beat. 
— The  force  and  exteitt  of  the  pulsation  may  be  increased  by  : 

1.  Hypertrophy  of  the  heart. 

2.  Forcible  action  of  the  heart  caused  by  emotional  or 
physical  excitement,  reflex  irritation,  drugs,  Graves's  disease, 
etc. 

3.  Thinning  of  the  chest-walls  and  shrinking  of  the  lungs, 
as  in  phthisis. 

A  weak  apex-beat  may  be  noted  : 

1.  In  health. 

2.  Degeneration  or  dilatation  of  the  heart. 

3.  Pericardial  effusion. 

4.  Emphysema. 

5.  Collapse  or  shock. 

Abnormal  Centers  of  Pulsation. — Epigastric  pidsa- 
tion  may  result  from  : 

I.  Excited  action  of  the  heart  from  any  cause. 


INSPE  C  TION.  1 6  J 

2.  Enlargement  of  the  right  ventricle. 

3.  A  pulsating  aorta,  noted  in  certain  nervous  and  anemic 
patients. 

4.  Aortic  aneurysm. 

5.  Tumors  of  the  left  lobe  of  the  liver  resting  on  the  aorta. 
Pulsation  at  the  base  of  the  heart  may  result  from  : 

1.  Aneurysm  of  the  aortic  arch. 

2.  Cardiac  hypertrophy. 

3.  Shrinking  of  the  lungs,  as  in  phthisis. 
Pulsation  in  the  left  axillary  region  may  result  from : 

1.  Enlargement  of  the  heart. 

2.  A  tense,  purulent  effusion  in  the  left  pleural  sac 
(pulsating  empyema). 

3.  Aneurysm. 

4.  Chronic  diseases  of  the  left  lung  and  pleura,  associated 
with  retraction. 

Unnatural  pulsation  in  the  carotids  may  result  from : 

1.  Excitement  of  the  heart  from  any  cause. 

2.  Exophthalmic  goiter. 

3.  Anemia. 

4.  Valvular  disease,  especially  aortic  regurgitation. 

5.  Aneurysm  or  dilatation  of  the  vessels. 

6.  Unnatural  elasticity  of  the  vessels,  noted  in  certain 
nervous  and  anemic  patients. 

Jugular  Pulsation. — The  jugular  vein  often  becomes 
distended  in  forced  expiration  and  coughing.  Distention 
of  the  jugular  vein  is  sometimes  noted  in  adherent  peri- 
cardium. 

A  true,  rhythmic  venous  pulsation  usually  results  from 
tricuspid  regurgitation. 

A  pulsation  may  be  transmitted  to  the  jugular  vein  from 
the  underlying  carotid,  but  this  false  pulsation  will  still  con- 
tinue when  light  pressure  is  made  on  the  vein  at  the  root 
of  the  neck,  while  the  true  venous  pulse  will  cease. 

Precordial  Prominence. —  Unnatural  prominence  of  the 
precordiuni  may  result  from  : 

1.  Hypertrophy  of  the  heart. 

2.  Dilatation  of  the  heart. 

3.  Pericardial  effusion. 


1 68         DISEASES   OF   THE    CIRCULATORY  SYSTEM. 

PALPATION. 

This  not  only  determines  the  position,  force,  extent,  and 
rhythm  of  the  apex-beat,  but  also  detects  the  existence  of 
any  fremitus  or  thrill. 

A  thrill  is  a  vibratory  sensation  likened  to  that  received 
when  the  hand  is  placed  on  the  back  of  a  purring  cat. 
Thrills  at  the  base  of  the  heart  may  result  from  aortic  steno- 
sis, atheroma  of  the  aorta,  aneurysm,  and  from  roughened 
pericardial  surfaces,  as  in  pericarditis. 

A  presystolic  thrill  at  the  apex  is  almost  pathognomonic 
of  mitral  stenosis. 

PERCUSSION. 

This  determines  the  shape  and  extent  of  the  cardiac  dul- 
ness. 

The  normal  area  of  superficial  or  absolute  percussion-dul- 
ness  (the  part  uncovered  by  lung)  is  detected  by  light  per- 
cussion, and  extends  from  the  fourth  left  costosternal  junc- 
tion to  the  apex-beat;  from  the  apex-beat  to  the  junction 
of  the  xiphoid  cartilage  with  the  sternum,  and  thence  up  the 
left  border  of  the  sternum. 

The  normal  area  of  deep  percussion-dulness  (the  heart  pro- 
jected on  the  chest-wall)  is  detected  by  firm  percussion,  and 
extends  from  the  third  left  costosternal  articulation  to  the 
apex-beat ;  from  the  apex-beat  to  the  junction  of  the  xiphoid 
cartilage  with  the  sternum,  and  thence  up  the  right  border 
of  the  sternum  to  the  third  rib.  The  lower  level  of  the 
cardiac  dulness  fuses  with  the  liver  dulness,  and  can  rarely 
be  determined  by  percussion. 

The  area  of  cardiac  duhtess  is  increased  in  :  (i)  Hyper- 
trophy and  dilatation  of  the  heart.  (2)  Pericardial  effusion. 
It  IS  apparently  increased  in  shrinking  of  the  lungs,  as  in 
phthisis. 

The  area  of  cardiac  dtdness  is  diminished  in  :  (i)  Emphy- 
sema. (2)  Pneumothorax.  (3)  Pneumopericardium  (rare). 
(4)  Gaseous  distention  of  the  stomach. 

AUSCULTATION. 

This  determines  the  quality,  intensity,  and  rhythm  of  the 
heart-sounds,  and  detects  the  presence  of  any  adventitious 
sounds,  as  murmurs.     The  two  sounds  heard  over  the  heart 


A  USCUL  TA  TION.  '  1 69 

have  been  represented  by  the  syllables,  **  lubb,  tup."  The 
first  sound  {systolic)  results  from  the  muscular  contraction  of 
the  heart  and  the  closure  of  the  auriculoventricular  valves, 
and  is  synchronous  with  the  apex-beat  and  carotid  pulse. 
This  sound  is  prolonged  and  dull.  After  the  first  sound 
there  is  a  short  pause,  and  then  follows  the  second  sound 
{diastolic),  which  results  from  the  closure  of  the  aortic  and 
pulmonary  valves.  This  sound  is  short  and  high-pitched. 
After  the  second  sound  a  longer  pause  follows  before  the 
first  is  again  heard. 

The  Intensity  of  the  Heart-sounds. — Both  sounds 
are  accentuated  in:  (i)  Excitement  of  the  heart  from  any 
cause.  (2)  Anemia.  (3)  Cardiac  hypertrophy.  (4)  Sub- 
jects with  thin  chest-walls.  (5)  Consolidation  of  the  lung, 
as  in  phthisis  and  pneumonia. 

Accentuation  of  the  aortic  second  sound  results  from  :  (1) 
Hypertrophy  of  the  left  ventricle.  (2)  High  arterial  tension, 
as  in  chronic  interstitial  nephritis  with  arteriosclerosis.  (3) 
Aortic  aneurysm. 

Weakejiing  of  the  aortic  second  sotind  indicates  weakness 
of  the  left  ventricle. 

Accentuation  of  the  pulmonary  seco?id  sound  results  from  : 
(i)  Pulmonary  obstruction,  as  in  emphysema,  pneumonia, 
and  the  congestion  of  the  lungs  following  mitral  disease. 
(2)   Hypertrophy  of  the  right  ventricle. 

Weakness  of  the  pulmonary  sound  indicates  failure  of  the 
right  ventricle,  and,  occurring  in  diseases  in  which  it  should 
be  accentuated,  is  of  grave  omen. 

Weakness  of  the  mitral  sound  is  noted  in:  (i)  General 
obesity.  (2)  General  exhaustion.  (3)  Degeneration  or 
dilatation  of  the  heart.  (4)  Pericardial  or  pleural  effusion. 
(5)  Emphysema. 

Alteration  in  the  Rhythm  of  the  Heart-sounds. — 
Reduplication  of  the  Diastolic  Sounds. — This  is  probably 
due  to  a  lack  of  synchronism  in  the  closure  of  the  aortic 
and  pulmonary  valves.  It  is  frequently  noted  in  health  at 
the  end  of  a  long  inspiration.  Pathologic  reduplication 
may  occur  whenever  the  pressure  in  either  the  pulmonary 
circulation  or  the  peripheral  arteries  is  abnormally  increased. 


I/O         DISEASES   OF   THE    CIRCULATORY  SYSTEM. 

It  is  a  common  sign  in  mitral  stenosis,  emphysema,  arterio- 
sclerosis, and  pericarditis. 

Embryocardia. — This  term  is  used  to  indicate  a  rhythm 
that  resembles  that  of  the  fetal  heart.  The  pauses  between 
the  sounds  are  of  equal  length,  and  the  two  sounds  are 
exactly  alike.  Embryocardia  indicates  great  enfeeblement 
of  the  heart  and  may  be  observed  in  low  fevers  and  in  car- 
diac failure  from  any  cause. 

Gallop  or  Cantering  Rhythm. — This  suggests  the  hoof-beats 
of  a  galloping  horse.  One  of  the  cardiac  sounds  is  doubled 
and  the  diastolic  pause  is  shortened.  It  indicates  extreme 
weakness  of  the  heart. 

Adventitious  Sounds. — Murmurs  are  abnormal  sounds 
produced  in  the  heart  or  blood-vessels.  They  may  result 
from  :  (i)  Obstruction  or  regurgitation  at  the  valves  in  con- 
sequence of  valvular  endocarditis.  (2)  Dilatation  of  the 
ventricle  or  relaxation  of  its  walls,  in  consequence  of  which 
the  auriculoventricular  valves  become  relatively  insufficient. 
(3)  Roughening  of  the  valves  or  of  the  intima  of  the  great 
vessels.    (4)  Aneurysm  (bruit).    (5)  Anemia  (hemic  murmur). 

Exocardial  murmurs  are  adventitious  sounds  of  cardiac 
origin  produced  in  the  pericardium  (pericardial  friction- 
sound)  or  in  the  pleura  or  lung,  adjacent  to  the  heart 
(pleuropericardial  friction-sound  and  cardiorespiratory  mur- 
mur). 

Pericardial  Friction-sound. — This  is  an  adventitious  sound 
produced  in  pericarditis  by  roughening  of  the  serous  mem- 
brane. It  is  a  harsh,  grating,  to-and-fro  sound,  quite  super- 
ficial, often  intensified  by  pressure  with  the  stethoscope,  and 
generally  heard  best  in  the  fourth  interspace  near  the  ster- 
num. It  often  varies  in  intensity  from  hour  to  hour,  and  is 
rarely  transmitted  beyond  the  precordial  region. 

Pleuropericardial  Friction-sound. — This  is  a  sound  closely 
resembling  the  pericardial  friction-sound,  but  produced  by 
inflammation  of  that  part  of  the  pleura  that  overlaps  the 
heart.  It  is  intensified  by  deep  inspiration,  and  often  dis- 
appears when  the  breath  is  held  during  expiration. 

Cardiorespiratory  Murmur. — This  is  a  rare  adventitious 
sound,  produced  by  the  rhythmic  expulsion  of  air  from  the 
lappet  of  lung  covering  the  heart  by  the  cardiac  contractions. 


THE   PULSE.  171 

The  exact  condition  under  which  it  occurs  is  not  known. 
It  is  usually  heard  best  at  the  end  of  inspiration,  and  is 
nearly  always  systolic  in  time.  It  is  greatly  modified  by 
position,  deep  breathing,  coughing,  and  holding  the  breath. 

Aneurysmal  Murmur,  or  Bruit. — In  a  certain  proportion  of 
cases  a  murmur  is  heard  in  aneurysm.  It  is  systolic  in 
time,  heard  with  greatest  intensity  over  the  sac  of  the 
aneurysm,  and  transmitted  into  the  vessels  of  the  neck. 
There  is  nothing  in  the  character  of  the  murmur  to  suggest 
its  origin. 

Hemic  Murmurs. — Hemic  murmurs  have  the  following 
characteristics  :  They  are  soft  and  blowing  in  character  ; 
they  are  usually  systolic  in  time  ;  they  are  usually  heard  best 
over  the  pulmonic  area  ;  they  are  associated  with  evidences 
of  anemia ;  they  are  not  accompanied  by  signs  of  cardiac 
enlargement ;  they  are  often  associated  with  a  continuous 
hum  in  the  veins  of  the  neck  ;  and  they  are  more  affected 
by  deep  breathing,  position,  and  exercise  than  the  murmurs 
of  organic  disease. 

THE  PULSE. 

The  average  frequency  of  the  pulse  in  the  healthy  adult 
at  rest  is  between  70  and  80.  In  new-born  infants  it  is 
between  130  and  140,  and  in  young  children  between  90 
and  100. 

Increased  Frequency  of  the  Pulse  (Tachycardia). 
— Habitual  frequency  is  sometimes  noted  in  health.  The 
frequency  may  be  temporarily  increased  by  erect  posture, 
excitement,  eating,  and  the  use  of  stimulants. 

Abnormal  frequeiicy  may  result  from — (i)  Pyrexia.  The 
pulse  usually  bears  a  definite  relation  to  the  temperature,  but 
in  certain  diseases,  as  scarlet  fever  and  septicemia,  it  may  be 
disproportionately  rapid,  and  in  others,  like  meningitis  and 
yellow  fever,  it  may  be  disproportionately  slow.  (2)  Ex- 
ophthalmic goiter.  (3)  Organic  heart  disease.  (4)  Lesions 
at  the  base  of  the  brain  sufficient  to  depress  the  pneumo- 
gastrics,  as  hemorrhage,  tumor,  and  advanced  meningitis. 
(5)  Reflex  irritation,  as  in  dyspepsia  or  ovarian  or  uterine 
disease.  (6)  An  independent  neurosis  (essential  paroxys- 
mal tachycardia).     (7)  Action  of  certain  drugs — belladonna, 


I'Jl        DSSEASES   OF   THE    CIRCULATORY  SYSTEM. 

nitrites,    thyroid    extract,    etc.      (8)    Rheumatoid     arthritis 
(Sansom). 

Infrequency  of  the  Pulse  (Bradycardia). — Physiolo^c 
slowness  is  noted  after  fasting,  sometimes  in  the  puerperium, 
and  habitually  in  certain  persons  (50  to  60  a  minute). 

Pathologic  i7ifrequency  is  observed  in  many  conditions, 
notably — (i)  In  certain  forms  of  organic  heart  disease,  es- 
pecially chronic  myocardial  disease  and  aortic  stenosis.  (2) 
In  jaundice.  (3)  From  pressure  at  the  base  of  the  brain  suffi- 
cient to  irritate  the  vagus,  as  in  beginning  meningitis,  tumor, 
etc.  (4)  At  the  close  of  febrile  diseases,  as  typhoid  fever, 
pneumonia,  etc.  (5)  After  the  use  of  certain  drugs,  as  digi- 
talis, aconite,  etc. 

Heart-block  (Adams -Stokes  Disease). — This  con- 
dition is  characterized  by  permanent  or  paroxysmal  brady- 
cardia, cerebral  attacks  of  an  epileptiform,  vertiginous,  or 
syncopal  character,  and  pulsations  of  the  cervical  veins  ex- 
ceeding in  rate  those  of  the  arteries.  It  depends  upon  a 
lesion  of  the  muscular  bundle  of  His  (a  narrow  band  extend- 
ing from  the  right  auricle  and  its  valves  to  the  interventric- 
ular septum),  in  consequence  of  which  the  auricles  con- 
tract more  or  less  normally,  but  the  ventricles  only  respond 
to  every  other,  every  second,  or  every  third  stimulus  (auric- 
ulo-ventricular  dissociation.) 

In  young  adults  Adams-Stokes  disease  is  often  of  syphil- 
itic origin ;  in  the  aged  it  is  usually  an  expression  of  myo- 
cardial degeneration. 

Irregular  Rhythm  (Arhythmia). — The  Intermittent 
Pulse. — This  per  se  is  not  characteristic  of  any  pathologic 
condition.  It  is  occasionally  met  with  in  healthy  persons, 
especially  after  exercise,  mental  excitement,  or  eating.  As 
a  pathologic  symptom  it  may  result  from  the  excessive  use 
of  tea,  coffee,  or  tobacco ;  from  organic  disease  of  the  heart, 
especially  myocarditis ;  reflex  irritation,  such  as  flatulent 
dyspepsia ;  gout,  neurasthenia,  or  hypochondriasis. 

The  Bigeminal  and  Trigeminal  Pulses. — These  are  pulses  in 
which  the  beats  occur  in  groups  of  two  or  three  respectively. 
They  are  most  frequently  seen  in  chronic  myocardial  disease 
and  in  uncompensated  mitral  stenosis,  especially  after  the 
too  free  use  of  digitalis. 


THE   PULSE.  173 

There  may  be  a  false  intermission  in  the  radial  pulse 
when  the  heart  fails  to  transmit  all  its  beats  to  the  wrist. 
This  condition  may  be  observed  in  any  disease  that  weakens 
the  ventricular  walls. 

The  Irregular  Pulse. — This  is  met  with  in  the  same  con- 
ditions as  the  intermittent  pulse.     It  may  be  habitual   or 


Fig.  8. — Sphygmogram  of  the  trigeminal  pulse. 

occasional.  There  is  often  marked  irregularity  in  uncom- 
pensated mitral  regurgitation  and  chronic  myocardial  dis- 
ease. Extreme  irregularity  with  rapidity  of  the  heart-beats 
is  spoken  of  as  delirium  cordis.  It  occurs  in  the  late  stages 
of  uncompensated  heart  disease. 

The  Pulsus  Paradoxus. — This  is  a  pulse  in  which  the  wave 
becomes  small  and  feeble  during  full  inspiration.  It  is 
sometimes  observed  in  healthy  persons.  It  is  not  infrequent 
in  adherent  pericardium. 

The  Dicrotic  Pulse. — This  is  a  pulse  in  which  the  main  beat 
is  quickly  followed  by  a  secondary  wave  or  slight  rebound  of 
the  vessel.  It  is  especially  apt  to  occur  when  the  tension  is 
low  and  the  arteries  are  relaxed,  as  in  low  fevers,  like  typhoid. 


Fig.  9. — Sphygmogram  of  a  dicrotic  pulse. 

Other  Variations  in  the   Pulse. — The  High-tension 

Pulse.  —  This  is  a  pulse  in  which  the  force  of  the  beat  is 
relatively  increased.  The  tension  may  be  roughly  estimated 
by  noting  the  amount  of  pressure  of  the  fingers  that  is  re- 
quired to  arrest  the  beat.  It  may  be  determined  more  accu- 
rately by  means  of  the  sphygmograph. 


174         DISEASES    OF   THE    CIRCULATORY  SYSTEM. 

A  high  tension  is  observed  in  many  conditions,  notably  in 
cardiac  hypertrophy ;  in  chronic  nephritis,  especially  inter- 
stitial nephritis  ;  in  arteriosclerosis  ;  in  certain  intoxications, 
like  gout,  chronic  lead-poisoning,  and  uremia ;  in  cerebral 
affections  irritating  the  vasometer  centers,  such  as  apoplexy 
and  tumor ;  and  in  contraction  of  the  arterioles,  as  in  chills 
and  in  some  paroxysms  of  angina  pectoris. 

The  Low-tension  Pulse. — A  low-tension  pulse  is  one  that 
is  soft  and  compressible.  It  is  observed  in  many  conditions, 
notably  in  marked  cardiac  degeneration,  in  collapse,  in  low 
fevers,  and  in  states  of  great  exhaustion  and  depression. 

Venous  Pulse. — A  true  jugular  pulsation  occurs  in  tricuspid 
regurgitation.  A  venous  pulse  in  the  dorsum  of  the  hand 
may  be  due  to  forcible  propulsion  of  the  blood  through  the 
capillaries,  as  in  compensated  aortic  regurgitation,  or  to  ex- 
treme relaxation  of  the  arterioles,  permitting  the  transmis- 
sion of  the  pulse-wave,  as  in  grave  anemia. 

Capillary  Pulse. — This  may  be  detected  by  the  occurrence 
of  systoHc  flushing  in  a  hyperemic  area  of  the  skin  (prefer- 
ably over  the  forehead)  caused  by  friction,  or  in  the  everted 
lip  which  has  been  somewhat  blanched  by  pressure  of  a 
glass  slide.  A  capillary  pulse  is  occasionally  observed  in 
aortic  regurgitation,  in  grave  anemia,  and  in  neurasthenia. 

Asymmetric  radial  pulses  may  result  from  :  (i)  Anomalies 
in  the  distribution,  size,  or  division  of  one  of  the  vessels. 
(2)  Aortic  aneurysm.  (3)  An  embolus  or  an  atheromatous 
plate  within  the  vessel.  (4)  Fractures,  luxations,  or  inflamma- 
tory exudations  causing  compression  of  the  vessel.  (5)  Com- 
pression of  one  vessel  by  tumors  within  or  without  the  thorax. 

"  Water-hammer  Pulse  "  (Corrigan's  Pulse). — This  pulse  is 
characterized  by  a  quick,  powerful  beat,  which  suddenly 
collapses  or  recedes.  The  peculiar  pulsation  may  be  dis- 
tinctly visible,  not  only  in  the  carotids,  but  throughout  the 
brachial  artery.  This  pulse  is  diagnostic  of  aortic  regurgi- 
tation during  the  period  of  compensation,  and  its  force  is  due 
to  the  excessive  ventricular  hypertrophy  and  to  the  large 
amount  of  blood  expelled  with  each  systole ;  its  sudden  re- 
cession is  due  to  the  incompetent  valves  faihng  to  support 
the  column  of  blood  in  the  aorta. 


PALPITATION—GENERAL    CYANOSIS.  1 75 

PALPITATION* 

Definition. — A  rapid  and  tumultuous  action  of  the  heart 
perceptible  to  the  patient.  Rapidity  not  perceptible  to  the 
patient  is  not  termed  palpitation. 

etiology. — It  may  result  from:  (i)  Reflex  irritation,  as 
from  flatulent  distention  of  the  stomach.  (2)  Excitement, 
mental  or  physical.  (3)  Organic  heart  disease.  (4)  Ex- 
ophthalmic goiter.  (5)  Overwork,  as  in  the  "  irritable  heart  " 
of  untrained  recruits.  (6)  Anemia.  (7)  Hysteria.  (8)  An 
independent  neurosis  (essential  paroxysmal  tachycardia). 

DROPSY* 

Definition. — An  unnatural  collection  of  serous  fluid  in 
the  tissues  or  cavities  of  the  body. 

Ktiology. — Dropsy  may  result  from  :  (i)  Chronic  vis- 
ceral affections  that  bring  about  venous  stasis,  as  chronic 
heart  disease,  cirrhosis  of  the  liver,  and  emphysema.  (2) 
Local  obstruction  to  the  venous  circulation  by  emboli, 
thrombi,  tumors,  etc.  (3)  Changes  in  the  composition  of 
the  blood,  as  in  anemia.  (4)  Increased  permeability  of  the 
capillary  walls,  as  in  Bright's  disease.  (5)  Disturbed  inner- 
vation, as  in  hysteria,  angioneurotic  edema,  and  neuritis. 

GENERAL  CYANOSIS* 

Definition. — Blueness  of  the  surface  from  insufficient  oxi- 
dation of  the  blood. 

Htiology. — Cyanosis  results  from:  (i)  Affections  pre- 
venting the  free  entrance  of  air  to  the  lungs,  as  in  laryngeal 
or  tracheal  stenosis,  asthma,  emphysema,  pneumonia ;  (2) 
obstruction  to  the  venous  return,  as  in  uncompensated  car- 
diac disease ;  (3)  congenital  heart  disease,  in  which  there  is 
venous  congestion  or  a  direct  admixture  of  arterial  with  ven- 
ous blood  ;  (4)  chronic  splenomegalic  polycythemia  (see  p. 
161);  (5)  conditions  associated  with  methemoglobinemia,  as 
acetanilid  or  antipyrin  poisoning. 


1/6        DISEASES   OF  THE   CIRCULATORY  SYSTEM. 

DISEASES  OF  THE  PERICARDIUM. 

PERICARDITIS. 

Definition. — Inflammation  of  the  pericardium. 

:^tiology.— (i)  It  is  usually  secondary  to  infectious  dis- 
eases, such  as  rheumatism,  chorea,  the  specific  fevers,  septi- 
cemia, and  tuberculosis.  (2)  It  may  result  from  the  exten- 
sion of  inflammation  from  the  pleura,  lung,  esophagus,  or 
the  heart  itself.  (3)  It  may  be  due  to  traumatism.  It  occa- 
sionally occurs  in  Bright's  disease.  The  organisms  most 
commonly  found  in  the  exudate  are  the  streptococci,  staphy- 
lococci, pneumococci,  and  tubercle  bacilli. 

Patholog-y.— In  the  early  stages  the  membrane  is  red 
sticky,  and  lusterless.  An  exudate  is  soon  formed,  which 
may  be  serofibrinous,  fibrinous,  or  purulent 

In  the  serofibrinous  form  there  is  but  little  inflammatory 
lymph  the  exudate  being  composed  mainly  of  straw-colored 
ttuid  (from  a  few  ounces  to  two  pints  or  more),  which  in 
favorable  cases  is  gradually  absorbed. 

In  the  fibrinous  form   serum  is  scant.     The  membrane  is 

covered  with  a  butter-hke  exudate,  which  subsequently  or- 

gamzes  mto  fibrous  tissue  and  unites  more  or  less  firmly  the 

pericardial   surfaces.     In    some    cases    the  development  of 

fibrous  pericarditis  is  insidious  and  unattended  by  any  acute 

symptoms.     The  adhesions  oflbr  resistance  to  the  ventricu- 

ar  contractions,  and  ultimately  induce  hypertrophy  and  dila- 
tation of  the  heart. 

In  the  purulent  form  the  sac  may  contain  from  a  few  ounces 
to  two  or  three  pints  of  pus.  Death  usually  results,  but 
evacuation  of  the  pus  is  occasionally  followed  by  union  of 
the  pericardial  surfaces  and  slow  recovery 

less"nvilvT'  °'  P"""'"'"  "^^  "^y-ardium  is  more  or 

Symptoms    of    Serofibrinous    Pericarditis.— The 

chief  symptoms  are  moderate  fever,  precordial   pain,  pal- 

SSh°"'h  7  'k,"^^'  ^""^  '^y^P"^^-      The  pulse  is  at  first ' 
rapd  and  forcible ;  later,  weak  and  irregular 

Physical  Signs._The  only  typical  sign  of  the  first  stage 


PERICARDITIS.  1/7 

(dry  pericarditis)  is  a  rough,  to-and-fro  friction  rub,  usually 
heard  best  at  the  fourth  left  intercostal  space,  and  not  trans- 
mitted beyond  the  precordium.  Pericardial  effusion  is  mani- 
fested by  several  definite  signs. 

Inspection. — The  precordium  may  bulge,  especially  in  chil- 
dren. 

Palpation. — A  friction  fremitus  is  occasionally  felt.  The 
apex-beat  is  feeble  or  lost.  A  pulsation  is  sometimes  felt  in 
the  fourth  interspace  to  the  left  of  the  mammary  line. 

Percussion. — There  is  a  large  pyramidal  area  of  dulness, 
with  the  apex  directed  upward.  A  triangular  area  of  dul- 
ness in  the  fifth  right  interspace  or  cardiohepatic  angle 
(Rotch's  sign)  is  a  trustworthy  sign.  A  dull  area  is  some- 
times detected  posteriorly  in  the  left  infrascapular  region. 

Auscultation. — The  heart-sounds  are  indistinct  and  muffled. 
They  are  often  disproportionately  feeble  compared  with  the 
strength  of  the  pulse. 

Purulent  Pericarditis. — The  symptoms  are  those  of  sero- 
fibrinous pericarditis  plus  those  of  sepsis — irregular  fever, 
chills,  sweats,  pallor,  and  marked  leukocytosis.  Occasionally 
the  precordial  tissues  are  edematous.  It  may  be  necessary 
to  aspirate  in  doubtful  cases. 

Adherent  Pericardium. — The  diagnosis  cannot  always  be 
made  during  life.  The  following  signs  are  suggestive : 
(i)  Enlargement  of  the  heart,  especially  of  the  right  ven- 
tricle ;  (2)  systolic  retraction  in  the  region  of  the  apex  and 
posteriorly  in  the  region  of  the  eleventh  and  twelfth  ribs 
(Broadbent's  sign) ;  (3)  collapse  of  the  cervical  veins  during 
diastole  ;  (4)  fixation  of  the  apex-beat,  so  that  it  does  not 
move  with  respiration  or  change  in  posture;  (5)  the  pulsus 
paradoxus  (see  p.  173).  With  these  signs  there  are  often 
symptoms  of  heart-failure — dyspnea,  cyanosis,  edema,  and 
hepatic  enlargement. 

Diagnosis. — Acute  Endocarditis. — The  endocardial  mur- 
mur is  soft,  not  harsh ;  it  is  systolic  or  diastolic,  not  to  and 
fro ;  it  is  more  distant ;  it  is  heard  loudest  at  a  valve-point, 
not  at  the  base  of  the  heart ;  it  is  not  confined  to  the  pre- 
cordium, and  is  not  followed  by  signs  of  effusion. 

Cardiac  hypertrophy  develops  slowly ;  the  impulse  is  pow- 
12 


1/8         DISEASES   OF   THE    CIRCULATORY  SYSTEM. 

erful,  the  apex-beat  is  displaced  downward,  and  the  sounds 
are  loud. 

Cardiac  Dilatation. — In  this  condition  the  area  of  dulness 
is  not  pyramidal  in  shape ;  the  enlargement  is  chiefly  down- 
ward and  does  not  extend  beyond  the  apex-impulse,  as  in 
effusion  ;  the  impulse  is  usually  visible  and  undulatory  ;  the 
line  of  demarcation  between  flatness  and  pulmonary  resonance 
is  not  so  abrupt  as  in  effusion  ;  and  the  sounds  are  usually 
clear  and  sharp. 

Prognosis. — In  the  dry  and  serofibrinous  forms  the 
prognosis  is  good  under  favorable  conditions.  In  the  puru- 
lent form  the  outlook  is  extremely  grave.  The  fibrinous 
form,  though  not  immediately  fatal,  is  very  serious  on  ac- 
count of  the  secondary  changes  that  it  induces  in  the  cardiac 
muscle. 

Treatment. — Absolute  rest  is  imperative.  Milk  is  the 
most  suitable  diet.  Locally,  an  ice-bag  is  serviceable. 
Leeching  is  beneficial  in  robust  subjects.  Blisters  are  useful 
when  there  is  great  pain.  Opium  is  often  necessary  to  secure 
rest  and  to  allay  pain.  If  heart-failure  occurs,  such  stimu- 
lants as  whisky,  strychnin,  digitalis,  and  caffein  must  be 
employed. 

Pericm'dial  Effusion. — When  the  eflusion  is  serous,  ab- 
sorption may  be  aided  by  the  application  of  small  blisters, 
by  the  administration  of  diuretics, — infusion  of  digitalis, — 
and  by  the  administration  of  saline  purges.  Potassium  iodid 
is  of  doubtful  efficacy.  Diaphoretics,  particularly  pilocarpin, 
should  not  be  used.  When  pressure  symptoms  become 
urgent  or  the  effusion  does  not  yield  after  a  thorough  trial 
to  the  measures  just  mentioned,  paracentesis  should  be  per- 
formed. The  most  suitable  site  for  the  puncture  is  in  the 
left  fifth  intercostal  space,  about  an  inch  or  an  inch  and  a 
half  from  the  edge  of  the  sternum. 

In  pericarditis  with  purulent  effusion  the  indications  are  to 
incise  the  sac  and  to  afford  the  freest  possible  outlet  for  the 
pus.  The  mortality  of  incision  is  about  60  per  cent.  In 
adherent  pericardium  the  treatment  is  that  of  dilatation. 


END  0  CA  RDITIS.  1 79 

OTHER  AFFECTIONS  OF  THE  PERICARDIUM* 

Hydropericardium   (dropsy  of  the  pericardium) 

results  from  one  of  the  causes  of  general  dropsy,  especially 
heart  disease  or  nephritis.  The  physical  signs  are  those  of 
serofibrinous  pericarditis  in  the  stage  of  effusion. 

Hemopericardium  (blood  in  the  pericardium)  may 
result  from  traumatism,  the  rupture  of  an  aneurysm,  or  the 
rupture  of  the  heart  itself.  In  cancerous  and  tuberculous 
pericarditis  the  serous  exudate  is  often  more  or  less  bloody. 

Pneumopericardium  (air  in  the  pericardium)  is 
very  rare.  It  may  result  from  traumatism  or  the  rupture  of 
a  neighboring  air-containing  organ.  Thus  it  may  be  pro- 
duced by  pneumopyothorax,  a  phthisic  cavity,  or  ulceration 
of  the  esophagus  or  stomach. 


DISEASES   OF  THE   HEART. 

ENDOCARDITIS. 

(Valvulitis.) 

Definition. — Inflammation  of  the  lining  membrane  of 
the  heart.     The  process  is  usually  confined  to  the  valves. 

Varieties. — (i)  Simple,  benign,  or  verrucose  endocarditis. 
This  begins  as  an  acute  affection,  but  usually  leads  to  chronic 
sclerotic  valvular  disease.  (2)  Ulcerative  or  malignant  endo- 
carditis. No  sharp  line,  either  clinically  or  anatomically, 
can  be  drawn  between  this  and  simple  endocarditis.  The 
terms  ulcerative  and  malignant  are  used  to  designate  a  more 
intense  infection.  (3)  Chronic  or  sclerotic  endocarditis.  This 
may  be  the  continuation  of  acute  endocarditis  or  it  may  be 
chronic  from  the  outset. 

]^tiolog"y. — Acute  endocarditis  usually  results  from  acute 
articular  rheumatism,  one  of  the  infectious  fevers,  chorea,  or 
septicemia.  Gonorrhea,  tuberculosis,  and  Bright's  disease 
are  occasional  causes.  At  least  40  per  cent,  of  all  cases  of 
acute  articular  rheumatism  are  complicated  with  endocarditis. 
The  young  are  more  liable  to  be  attacked  than  the  old. 
Sixty-two  of  73  fatal  cases  of  chorea  collected  by  Osier 
showed  endocarditis.  Of  the  infectious  fevers,  scarlatina 
and  pneumonia  are  most  prone  to  heart  complications. 


l80         DISEASES   OF   THE    CIRCULATORY  SYSTEM. 

The  ulcerative  type  is  prone  to  develop  on  valves  already 
the  seat  of  chronic  inflammation,  but  it  may  be  primary.  It 
generally  follows  septicemia,  pneumonia,  pneumococcus 
meningitis,  gonorrhea,  or  one  of  the  specific  fevers.  It  is 
very  rarely  due  to  rheumatism  or  chorea.  The  micro- 
organisms most  frequently  detected  in  the  lesions  are  the 
staphylococcus,  streptococcus,  and  the  pneumococcus. 

Chronic  endocarditis  may  be  congenital,  may  follow  an 
acute  attack,  or  may  result  directly  from  chronic  rheuma- 
tism, gout,  alcoholism,  syphilis,  or  chronic  nephritis.  Severe 
muscular  strain  sometimes  induces  it. 

Pathology. — Postnatal  endocarditis  most  commonly  in- 
volves the  valves  of  the  left  side  of  the  heart.  Prenatal 
endocarditis  most  commonly  involves  the  valves  of  the  right 
side  of  the  heart. 

In  simple  endocarditis  the  surface  of  the  valve  becomes 
red,  swollen,  and  lusterless.  Later,  a  row  of  bead-like 
vegetations  (thrombi)  appears  along  the  line  of  maximum 
contact,  which  is  about  2  mm.  from  the  free  margin  of  the 
valve.  Microscopically,  the  endothelium  beneath  the  vege- 
tations shows  evidence  of  necrosis,  and  the  adjacent  tissue,  a 
round-cell  infiltration.  The  vegetations  may  be  whipped 
off  by  the  blood-current  and  carried  to  distant  organs,  as  the 
brain,  kidney,  or  spleen  ;  but  in  the  vast  majority  of  cases,  if 
life  is  preserved,  they  are  transformed,  together  with  the  cell- 
ular exudate,  into  fibrous  tissue  (chronic  endocarditis)^  which. 
not  only  thickens  the  valves,  but,  by  contracting,  so  shortens 
and  distorts  them  that  they  are  rendered  in  one  instance 
obstructive  to  the  onward  flow  of  blood,  and  in  another  in- 
competent to  close  the  orifice  over  which  they  preside. 
Finally,  retrograde  changes  ensue,  the  thickened  valves  be- 
coming fatty  and  calcareous. 

The  myocardium  is  probably  more  or  less  involved  in 
every  case  of  endocarditis. 

The  idcerative  type  is  characterized  by  more  extensive 
necrosis,  the  development  of  ulcers,  and  the  passage  into  the 
circulation  of  septic  emboli. 

Symptoms  of  Acute  Simple  i^ndocarditis. — Sub- 


ENDOCARDITIS.  l8l 

jective  phenomena  are  often  absent,  and  auscultation  may 
furnish  the  only  indication  of  endocarditis — namely,  a  pro- 
longation of  the  heart-sound,  which  later  develops  into  a 
distinct  murmur. 

In  many  cases  fever,  an  irregular  and  rapid  pulse,  palpita- 
tion, precordial  distress,  and  dyspnea  are  associated  symp- 
toms. 

Symptoms  of  Acute  Ulcerative  l^ndocarditis. — 
The  general  symptoms  may  resemble  those  of  septicemia  or 
typhoid  fever.  Thus,  there  may  be  moderately  high  and 
irregular  fever,  profuse  sweats,  chills,  leukocytosis,  delirium, 
and  stupor.     Diarrhea  is  not  uncommon. 

Cardiac  Symptoms. — There  may  be  precordial  pain,  palpita- 
tion, dyspnea,  a  rapid  and  irregular  pulse,  and  a  murmur  at 
one.  or  other  of  the  valve-points.  This  murmur  is  prone  to 
change  considerably  in  intensity  and  in  timbre  from  day  to 
day.  Occasionally  there  is  no  murmur  or  other  evidence 
of  cardiac  inflammation. 

3.  Embolic  Symptoms. — Emboli  in  the  peripheral  vessels 
may  occasion  a  petechial  rash  ;  renal  embolism  may  occasion 
hematuria  ;  splenic  embolism,  a  painful  enlargement  of  the 
spleen  ;  and  cerebral  embolism,  paralysis. 

Diagnosis. — Typhoid  Fever. — The  gradual  onset,  the 
more  regular  fever,  the  abdominal  symptoms,  the  roseolar 
rash,  the  Widal  reaction,  the  bronchial  catarrh,  the  early  en- 
largement of  the  spleen,  and  the  absence  of  leukocytosis  and 
of  embolic  phenomena  will  serve  to  separate  typhoid  fever 
from  ulcerative  endocarditis. 

Malarial  Fever. — This  may  be  recognized  by  the  presence 
of  the  malarial  parasite  in  the  blood. 

Prognosis. — Acute  simple  endocarditis  does  not  often 
prove  fatal,  but  it  rarely  leaves  the  valve  undamaged.  Under 
favorable  conditions,  however,  compensatory  hypertrophy  of 
the  heart  ensues  and  good  health  is  preserved  for  an  indefi- 
nite period.  Rapid  dilatation  of  the  heart  indicates  concur- 
rent myocarditis  and  is  a  serious  sign.  Ulcerative  endocarditis 
generally  proves  fatal  in  from  one  to  eight  weeks.  Occa- 
sionally the  disease  lasts  several  months. 

Treatment. — The   treatment   of    acute   endocarditis   is 


1 82         DISEASES   OF   THE    CIRCULATORY  SYSTEM. 

mainly  that  of  the  causal  condition.  Prolonged  and  coinplete 
rest  is  of  the  greatest  importance.  The  patient  should  be 
confined  to  bed  not  only  during  the  attack,  but  for  several 
weeks  after  it  has  subsided,  in  order  to  allow  sufficient  time 
for  the  damage  to  be  repaired  or  for  compensatory  hyper- 
trophy to  be  established. 

Externally,  an  ice-bag  is  often  useful  in  allaying  excitement 
of  the  heart.  Mild  mercurial  or  sahne  aperients  may  be 
used  from  time  to  time  for  their  depurative  effect.  Digitalis 
may  be  of  service  when  the  pulse  is  weak  and  irregular,  but 
generally  it  is  not  indicated.  Heart-failure  is  to  be  combated 
by  such  stimulants  as  alcohol,  ammonia,  strychnin,  and 
caffein.  Repeated  vesication  and  the  prolonged  use  of 
potassium  iodid  have  been  warmly  advocated, 

CHRONIC  VALVULAR  DISEASE, 

PERIOD  OF  COMPENSATION* 

Compensation  is  effected  by  an  increase  in  the  strength 
and  size  of  certain  cardiac  chambers  sufficient  to  enable  the 
arterial  system  to  receive  its  normal  supply  of  blood,  notwith- 
standing obstruction  or  regurgitation  at  one  or  more  of  the 
valves. 

The  duration  of  this  period  is  indefinite,  and  depends 
largely  on  the  amount  of  damage  sustained  by  the  heart  and 
the  hygienic  conditions  to  which  the  patient  is  subjected. 

During  perfect  compensation  endocarditis  is  indicated  by 
physical  signs,  symptoms  being  entirely  absent. 

Aortic  Stenosis  or  Aortic  Obstruction. — Definition. — 
Obstruction  to  the  flow  of  blood  into  the  aorta  from  thicken- 
ing or  adhesion  of  the  aortic  segments.  Uncomplicated  aortic 
stenosis  is  a  rare  lesion.    It  occurs  usually  in  elderly  persons. 

Physical  Signs. — hispeciion. — If  the  heart  is  strong,  the 
apex-beat  is  forcible  and  is  noted  downward  and  to  the  left. 

Palpation  confirms  inspection,  and  often  detects  a  systolic 
thrill  at  the  base  of  the  heart. 

Percussion  may  yield  an  increased  area  of  cardiac  dulness, 
especially  to  the  left. 

Auscultation. — There  is  a  harsh  systolic  murmur,  heard 


CHRONIC    VALVULAR   DISEASE.  1 83 

best  in  the  second  right  intercostal  space,  and  transmitted  in 
the  large  vessels  of  the  neck.  The  aortic  second  sound  is 
often  inaudible  or  very  feeble. 

Pulse. — The  pulse  is  apt  to  be  small  and  infrequent ;  the 
wave  is  long  and  slow  to  rise  ^pulsus  tardus). 

Compensation. — 'From  obstruction  to  the  outflow  of  blood 
the  left  ventricle  becomes   hypertrophied. 

Sequence. — Mitral  regurgitation.  Weakening  and  dilata- 
tion of  the  left  ventricle  prevent  perfect  closure  of  the  mi- 
tral orifice,  and  relative  insufficiency  results. 

Diagnosis. — The  harshness  of  the  murmur,  weakness  of 
the  second  sound,  palpable  thrill,  enlargement  of  the  left 
ventricle,  and  especially  the  characteristic  pulse  will  serve 
to  distinguish  this  murmur  from  a  basilar  systolic  murmur 
caused  by  anemia  or  aortic  atheroma. 

Aortic  Insufficiency  or  Aortic  Regurgitation. — 
Definition. — Failure  of  the  aortic  valves  to  prevent  a  return 
of  blood  to  the  ventricle,  from  rupture  or  inflammatory 
contraction  of  the  segments,  or  from  dilatation  of  the  orifice. 
It  is  most  frequently  seen  in  middle-aged  men,  especially  in 
those  who  have   done  hard  manual  work. 

Physical  Signs. — Inspection. — The  apex-beat  is  forcible, 
and  displaced  downward  and  to  the  left.  There  is  often 
bulging  of  the  precordium. 

Palpation. — This  confirms  inspection. 

Percussion. — There  is  a  marked  increase  in  the  area  of 
cardiac   dulness,   especially  toward  the  left  and   downward. 

Auscultation. — There  is  a  diastolic  murmur,  heard  most 
distinctly  in  the  second  right  intercostal  space,  and  trans- 
mitted down  the  sternum  and  toward  the  apex.  A  pre- 
systolic murmur  (Flint  murmur)  is  sometimes  heard  at  the 
apex.  It  is  probably  due  to  the  impact  of  the  regurgitant 
stream  upon  the  anterior  mitral  leaflet. 

Pulse. — The  arteries,  especially  the  carotids,  brachials,  and 
radials,  pulsate  visibly.  Palpation  detects  the  "  water-ham- 
mer "  or  Corrigan's  pulse — i.  e.,  a  short,  full,  and  receding 
pulse. 

The  extreme  cardiac  enlargement  makes  the  pulse  full, 
and  the  prompt  leakage  back   into   the  ventricle   makes  it 


1 84         DISEASES   OF   THE   CIRCULATORY  SYSTEM. 

short  and  receding.  Elevation  of  the  arm  during  palpation 
of  the  radial  artery  makes  this  pulse  more  apparent,  as  the 
position  favors  regurgitation.  A  capillary  pulse  is  sometimes 
present.  It  may  be  noted  at  the  root  of  the  finger-nail  by 
an  alternate  blushing  and  paling,  synchronous  with  the 
heart-beats. 

Compensation. — Dilatation  and  hypertrophy  of  the  left 
ventricle.  Dilatation  results  from  the  reception  of  such  a 
large  quantity  of  blood  during  diastole,  and  hypertrophy 
follows  from  the  increased  effort  which  the  ventricle  must 
put  forth  in  emptying   itself  of  this  extra  quantity  of  blood. 

This  extremely  dilated  and  hypertrophied  heart  has  been 
called  the  coj'-  bovinum,  or  ox-heart. 

Sequence. — Mitral  regurgitation.  The  dilatation  and 
weakening  of  the  ventricle  prevent  perfect  closure  of  the 
mitral  orifice,  and  relative  insufficiency  results.    " 

Mitral  Stenosis  or  Mitral  Obstruction. — Definition. 
— Obstruction  to  the  flow  of  blood  through  the  mitral  orifice, 
from  thickening  or  adhesion  of  the  mitral  segments. 

It  is  usually  seen  in  early  life,  and  is  more  common  in 
females  than  in  males. 

Physical  Signs. — Inspection. — The  apex-beat  is  not  much 
displaced.  There  is  sometimes  bulging  over  the  lower  part 
of  the  sternum. 

Palpation. — There  is  a  rough  presystolic  thrill  near  the 
apex. 

Percussion. — The  area  of  dulness  is  increased  to  the  right 
of  the  sternum. 

Auscultation. — A  presystolic  murmur  is  heard  a  little 
within  the  apex,  and  is  not  transmitted.  This  murmur  is 
prolonged,  rough,  and  churning  in  character,  increases  in 
loudness  as  it  approaches  the  first  sound,  and  ends  in  an 
abrupt  systolic  shock.  The  pulmonic  second  sound  is 
accentuated. 

Pulse. — During  the  period  of  compensation  the  pulse 
is  small  and  regular.  After  failure  of  compensation  there 
is  often  extreme  irregularity,  both  in  force  and  in  rhythm. 

Compensation. — From  obstruction  to  the  outflow  of  blood 
the  left  auricle  becomes  enlarged;    when  it  loses    power, 


CHRONIC    VALVULAR  DISEASE.  1 85 

the  blood  accumulates  in  the  lung,  and  to  overcome  this 
pulmonary  resistance  the  right  ventricle  becomes  hyper- 
trophied. 

There  is  no  strain  on  the  left  ventricle,  and  hence  that 
chamber  is  not  enlarged. 

Sequence. — Tricuspid  regurgitation.  Dilatation  of  the 
right  ventricle  prevents  perfect  closure  of  the  tricuspid 
orifice,  and  relative  insufficiency  results. 

Diagnosis. — The  loud  systolic  shock,  accentuation  of  the 
pulmonic  second  sound,  and  enlargement  of  the  right  ven- 
tricle will  serve  to  distinguish  this  murmur  from  the  Flint 
murmur  (see  p.  183). 

Mitral  Insufficiency  or  Mitral  Regurgitation. — 
Definition. — Imperfect  closure  of  the  mitral  orifice  from 
rupture  or  inflammatory  contraction  of  the  mitral  segments  ; 
or  from  dilatation  or  weakening  of  the  left  ventricle,  pre- 
venting perfect  coaptation  of  normal  valves.  Mitral  regur- 
gitation is  the  most  frequent  of  the  valvular  defects. 

Physical  Signs. — hispection. — The  apex  is  usually  to  the 
left  and  downward.  There  may  be  bulging  of  the  precor- 
dium.     Palpation  confirms  inspection. 

Percussion. — The  area  of  dulness  is  increased  transversely, 
especially  toward  the  right. 

Auscultation. — The  murmur  is  systolic,  loudest  at  the 
apex,  and  transmitted  to  the  left  axilla  and  angle  of  the 
scapula.     The  pulmonic  second  sound  is  accentuated. 

Pulse. — During  the  period  of  compensation  the  pulse 
may  be  full  and  regular.  It  usually  becomes  quite  irreg- 
ular when  the  heart  weakens. 

Compensation. — The  left  auricle  enlarges  from  the  extra 
amount  of  blood  that  it  receives ;  when  it  weakens,  the 
lungs  become  congested  and  right  ventricular  hypertrophy 
follows. 

The  left  ventricle  also  becomes  hypertrophied,  from  its 
effort  to  move  the  large  quantity  of  blood  which  it  receives 
from  the  distended  auricle  during  each  diastole. 

Sequence. — Tricuspid  regurgitation.  Weakening  and  di- 
latation of  the  right  ventricle  prevent  perfect  closure  of  the 
tricuspid  orifice. 


1 86         DISEASES   OE  THE    CIRCULATORY  SYSTEM. 

Tricuspid   Stenosis  or  Tricuspid  Obstruction. — 

This  lesion  is  extremely  rare,  and  difficult  to  distinguish 
from  mitral  stenosis,  with  which  it  is  usually  associated.  It 
gives  rise  to  a  transverse  enlargement  of  the  heart  and  a 
presystoHc  murmur,  which  is  heard  loudest  over  the  base 
of  the  ensiform  cartilage. 

Tricuspid  Insufficiency  or  Tricuspid  Regurgita- 
tion.— Definition. — Imperfect  closure  of  the  tricuspid  orifice 
from  inflammatory  shortening  of  the  valves ;  or,  more  com- 
monly, from  dilatation  of  the  right  ventricle  secondary  to 
mitral  disease  or  to  chronic  lung  disease. 

Physical  Signs. — The  characteristic  signs  are  enlargement 
of  the  heart,  especially  to  the  right  of  the  sternum  ;  a  sys- 
tolic murmur,  loudest  over  the  lower  portion  of  the  ster- 
num ;  a  systolic  pulse  in  the  jugular  veins  and  in  the  liver. 

Pulmonary  Stenosis  or  Pulmonary  Obstruction. — 
This  very  rare  lesion  is  always  congenital.  It  may  be  sus- 
pected when  there  are  marked  enlargement  of  the  right 
ventricle,  a  systolic  murmur  in  the  second  left  intercostal 
space  which  is  not  transmitted  into  the  vessels  of  the  neck, 
a  systolic  thrill  in  the  same  area,  and  persistent  cyanosis. 

Pulmonary  Insufficiency  or  Pulmonary  Regurgi- 
tation.— This  is  very  rare,  and  is  usually  congenital.  It  pro- 
duces a  diastolic  murmur  in  the  second  left  intercostal  space. 

PERIOD  OF  BROKEN  COMPENSATION. 

Broken  compensation  usually  results  from  :  (i)  Increasing 
damage  to  the  valves  ;  (2)  senility,  leading  to  arterial  and  car- 
diac degeneration  ;  (3)  some  intercurrent  disease,  throwing 
additional  strain  on  the  heart;  or  (4)  undue  physical  exertion. 

During  this  period  subjective  symptoms  appear.  In  car- 
diac insufficiency,  no  matter  what  the  original  valvular  lesion 
may  have  been,  the  heart  becomes  unable  to  fill  the  arte- 
ries, and  the  blood  is  dammed  back  in  the  lungs,  and  venous 
congestion  of  the  organs  follows. 

Symptoms. — Pulmonary  congestion  produces  dyspnea, 
hemoptysis,  and  often  chronic  bronchial  catarrh  with  cough 
and  expectoration. 

Hepatic,  stomachic,  and   intestinal    congestion    produces 


CHRONIC    VALVULAR  DISEASE.  1 8/ 

dyspepsia.  Renal  congestion  produces  scanty,  albuminous 
urine,  and  later  nephritis. 

General  venous  congestion  produces  cyanosis  and  dropsy. 
The  latter  is  first  noted  in  the  feet. 

Disturbances  of  the  cerebral  circulation  produce  head- 
ache, vertigo,  and  syncopal  attacks. 

In  aortic  disease,  especially  aortic  stenosis,  cerebral  syrrip- 
toms  are  often  marked.  In  mitral  disease  pulmonary  symp- 
toms are  usually  marked. 

Prognosis  of  Chronic  Valvular  Aflfections. — Ihe 

extent  of  damage  can  never  be  accurately  determined  by 
the  quality  or  intensity  of  the  murmur. 

All  things  being  equal,  the  following  is  probably  the 
order  of  gravity  of  the  various  valvular  lesions  :  (i)  Tricus- 
pid regurgitation  ;  (2)  aortic  regurgitation ;  (3)  mitral  steno- 
sis ;  (4)  aortic  stenosis  ;  and  (5)  mitral  regurgitation.  Sudder. 
death  is  rare,  except  in  aortic  regurgitation. 

The  following  conditions  are  unfavorable :  Early  chilci- 
hood,  advanced  years,  distinct  liability  to  recurring  attack?? 
of  rheumatism,  great  cardiac  enlargement,  irregular  heart- 
action,  symptoms  of  pulmonary,  gastric,  and  renal  conges- 
tion, and  poor  hygienic  surroundings. 

In  proportion  to  the  absence  of  these  conditions  the 
prognosis  becomes  favorable.  In  many  cases  life,  is  not 
materially  shortened. 

Treatment. — When  compensation  is  well  maintained, 
the  treatment  should  be  purely  hygienic. 

Stage  of  Broke?!  Contpensation. — Absolute  rest  is  the  most 
important  element  in  the  treatment.  The  diet  should  be 
nutritious  but  readily  digestible.  In  some  cases  it  may  be 
well  to  restrict  the  diet  for  a  time  to  milk,  giving  3  or  4 
ounces  every  two  hours.  The  most  reliable  cardiac  stimu- 
lant is  digitalis  (10  to  20  minims  of  the  tincture  two  or  three 
times  a  day).  It  may  be  given  in  any  form  of  valvular  dis- 
ease when  there  are  dyspnea,  edema,  deficient  urination, 
and  a  frequent,  weak,  irregular  pulse.  Strophanthus,  spar- 
tein,  and  caffein  sometimes  succeed  when  digitalis  fails. 
Strychnin  is  the  most  valuable  adjuvant  to  digitalis,  espe- 


l88        DISEASES  OF  THE   CIRCULATORY  SYSTEM. 

cially  when  there  are  degenerative  changes  in  the  heart. 
Mercurial  and  saline  aperients  are  useful  in  lowering  venous 
tension,  and  without  their  aid  digitalis  may  fail.  When  the 
right  ventricle  is  greatly  overdistended  and  cyanosis  is 
marked,  venesection  to  the  extent  of  a  pint  or  more  may 
prove  life-saving.  Iron  and  arsenic  are  very  serviceable 
when  there  is  anemia.  They  may  sometimes  be  combined 
advantageously  with  digitalis  and  strychnin,  as  in  the  follow- 
ing pill : 

R.     Arseni  trioxidi '.....  gr.  i 

Massse  ferri  carbonatis gr.  xx 

Strychninse  sulphatis gr.  ss 

Pulveris  digitalis gr.  x-xx.— M. 

Fiant  pilulse  No.  xx. 

SiG. — One  pill  after  meals. 

Special  Symptoms. — Dropsy, — The  most  useful  measures 
are  hydragogue  cathartics  (salines  in  concentrated  solution  ; 
compound  jalap  powder,  30  to  40  grains ;  and  elaterium, 
■|-  grain);  diuretics  (digitahs,  caffein,  vegetable  salts  of  potas- 
sium) ;  the  application  of  smooth,  firm  bandages  to  the  limbs  ; 
the  introduction  of  fine  silver  cannulae  (Southey's  tubes),  and 
incisions  behind  the  ankles. 

Dyspnea  may  yield  to  cupping,  sinapisms,  the  administra- 
tion of  Hoffmann's  anodyne,  and,  in  cases  of  high  arterial 
tension,  to  nitrites.  Morphin  is  especially  useful  in  relieving 
nocturnal  dyspnea. 

Restlessness  and  Insomnia. — On  the  whole,  morphin 
{\  grain)  with  atropin  {j\^  grain)  is  the  best  sedative.  Tri- 
onal,  bromids,  and  chloralamid  are  worthy  of  confidence. 

Pai7t. — Temporary  oppression  is  often  relieved  by  warm 
or  cold  applications  and  the  administration  of  Hoffmann's 
anodyne.  Severe  continuous  pain  may  yield  to  leeching  or 
blistering.  In  anginoid  pains  nitrites  and  potassium  iodid 
are  often  efficacious. 

Sudden  heart-failure  must  be  met  by  the  administration 
of  diffusible  stimulants,  such  as  ammonia,  whisky,  and  ether. 
The  appHcation  of  heat  to  the  precordium  is  useful. 


ENLARGEMENT  OF  THE  HEART.  1 89 

ENLARGEMENT  OF   THE  HEART* 

Varieties. — (i)  Simple  Hypertrophy. — The  muscle  of  the 
heart  is  increased  in  thickness,  but  the  cavities  are  of  normal 
size. 

(2)  Eccentric  Hypertrophy  (Hypertrophy  with  Dilatation). — 
The  muscle  is  thickened  and  the  cavities  are  increased  in 
size. 

(3)  Simple  Dilatation. — The  muscle  is  thinned  and  the 
cavities  are  increased  in  size. 

Ktiology. — Hypertrophy  \.?>  always  the  result  of  increased 
demands  upon  the  functions  of  the  heart.  Thus,  it  may  be 
due  to — (i)  Valvular  disease;  (2)  abnormal  resistance  in 
the  peripheral  circulation,  as  in  arteriosclerosis  and  chronic 
Bright's  disease  (left  ventricle) ;  (3)  abnormal  resistance  in 
the  pulmonary  circulation,  as  in  emphysema  and  cirrhosis 
of  the  lung  (right  ventricle) ;  (4)  prolonged  exertion,  as  in 
athletes  ;  (5)  long-continued  palpitation  or  tachycardia,  as  in 
exophthalmic  goiter  or  tobacco  heart ;  (6)  interference  with 
the  ventricular  contractions  by  pericardial  adhesions. 

Dilatation  of  the  heart  results  from  the  same  causes.  It 
is  more  apt  to  occur  than  hypertrophy  when  the  demands 
are  sudden  and  severe,  or  when  they  fall  upon  a  heart  the 
walls  of  which  are  already  degenerated. 

Pathology. — In  hypertrophy  the  muscle  of  the  heart  is 
firm  and  of  a  dark-red  color.  The  normal  weight  (8  or  9 
ounces)  may  be  doubled  or  trebled.  When  the  left  ventricle 
is  chiefly  involved,  the  organ  is  increased  in  length.  When 
the  right  ventricle  is  chiefly  involved,  the  organ  becomes 
more  globular.  Microscopically,  the  fibers  are  increased  in 
size  and  in  number. 

In  dilatation  the  heart  muscle  is  softer,  more  flabby,  and 
often  lighter  in  color  from  degenerative  changes. 

Symptoms. — Hypertrophy. — Unless  the  hypertrophy  is 
more  than  compensatory,  no  symptoms  result.  Excessive 
hypertrophy  may  give  rise  to  precordial  distress  and  symp- 
toms of  cerebral  hyperemia — headache,  tinnitus  aurium, 
flashes  of  light,  etc. — and  the  following  physical  signs  : 
bulging  of  the  precordium,  a  heaving  impulse,  displacement 


190         DISEASES   OE   THE    CIRCULATORY  SYSTEM. 

of  the  apex-beat  downward  and  to  the  left,  an  increase  in 
the  area  of  cardiac  dulness,  a  loud,  booming  first  sound, 
accentuation  of  the  aortic  second  sound  or  of  the  pulmonic 
second  sound,  according  as  the  hypertrophy  involves  the 
left  or  right  ventricle,  and  a  strong,  full  pulse. 

Dilatation  also  gives  signs  of  cardiac  enlargement,  but  the 
impulse  is  feeble  or  imperceptible,  the  first  sound  is  short 
and  weak  (cHcking),  the  pulse  is  rapid  and  feeble,  and  often 
irregular  or  intermittent,  and  usually  there  are  symptoms  of 
venous  congestion — dyspnea,  cough,  edema,  flatulent  dys- 
pepsia, and  deficient  urination.  Soft  systolic  murmurs,  the 
result  of  relative  mitral  or  tricuspid  insufficiency,  may  be 
heard. 

Treatment. — In  hypertrophy  treatment  is  rarely  called 
for.  Mercurial  and  saline  aperients  are  useful  in  lowering 
arterial  tension.  Aconite  may  be  used  cautiously.  The 
cerebral  symptoms  will  generally  yield  to  bromids  or  to 
vasodilators,  Hke  the  nitrites. 

The  treatment  of  dilatation  is  for  the  most  part  that  of 
valvular  disease  in  the  stage  of  broken  compensation.  Digi- 
talis, strophanthus,  and  strychnin  are  the  most  reliable 
remedies  in  chronic  cases.  In  acute  cases  diffusible  stimu- 
lants— alcohol,  ether,  ammonia — will  be  required.  When 
the  right  heart  is  especially  embarrassed  and  there  is  or- 
thopnea with  cyanosis,  venesection  is  often  of  the  greatest 
value. 

ACUTE  MYOCARDITIS, 

Definition. — Acute  inflammation  of  the  heart  muscle. 

^Etiology. — It  results  from  the  same  causes  as  acute 
endocarditis. 

Pathology. — It  is  usually  associated  with  endocarditis 
or  pericarditis.  Occasionally  the  myocardium  is  the  only 
part  of  the  heart  affected.  The  inflammatory  process  is 
always  accompanied  with  more  or  less  parenchymatous  or 
fatty  changes  in  the  muscle-fibers.  The  essential  lesion  is 
the  infiltration  of  the  interstitial  tissue  with  round  cells. 

Symptoms. — The  symptoms  are  often  masked  by  the 
primary  disease.     Dyspnea,  precordial  distress,  palpitation, 


CHRONIC  MYOCARDIAL   DISEASE.  I9I 

pallor,  a  feeble  impulse,  a  rapid,  weak,  irregular,  and  un- 
stable pulse,  and  muffling  of  the  heart-sounds  may  suggest 
the  condition.     The  heart  may  or  may  not  be  dilated. 

Treatment. — The  treatment  is  that  of  acute  endocarditis. 
Cardiac  stimulants — strychnin,  alcohol,  ammonia,  camphor, 
and  caffein — are  indicated. 


CHRONIC  MYOCARDIAL  DISEASE. 

The  chief  chronic  affections  of  the  myocardium  are  fatty 
infiltration,  fatty  degeneration,  and  fibroid  induration  (chronic 
interstitial  myocarditis). 

Fatty  Infiltration. — This  consists  in  an  excess  of  the  fat 
which  is  normally  present  in  variable  amounts  beneath  the 
epicardium,  especially  along  the  blood-vessels  and  in  the 
g-rooves.  In  advanced  cases  the  fat  is  also  found  between 
the  muscle-fibers.  The  latter  may  remain  normal  for  a  long 
period,  but  ultimately,  owing  to  compression,  they  undergo 
atrophy  and  fatty  degeneration.  Fatty  infiltration  results 
from  the  causes  which  lead  to  general  obesity.  Thus,  it  may 
be  induced  by  an  hereditary  tendency,  by  overeating  and 
drinking,  and  by  sedentary  habits. 

Fatty  Degeneration. — This  is  a  degeneration  of  the  mus- 
cle-fibers themselves,  with  the  formation  of  fat.  It  is  fre- 
quently due  to  local  anemia  from  sclerosis  of  the  coronary 
arteries  ;  it  follows  hypertrophy  in  valvular  disease ;  it  is  a 
common  result  of  malnutrition  from  old  aa-e,  wastincr  dis- 
eases,  or  grave  anemia ;  it  is  associated  with  parenchymatous 
degeneration  (cloudy  swelling)  in  severe  infections  ;  it  occurs 
also  in  acute  mineral  poisoning,  as  by  phosphorus,  antimony, 
or  arsenic. 

The  muscle  of  the  heart  is  pale,  soft,  and  flabby,  and  feels 
greasy  to  the  touch.  Microscopically,  the  fibers  are  found 
filled  with  small,  dark  fat-granules. 

Fibroid  Induration. — This  is  met  with  as  a  replacement 
fibrosis  secondary  to  sclerosis  of  the  coronary  arteries.  It 
may  be  secondary,  however,  to  chronic  endocarditis  or  peri- 
carditis. The  indirect  causes  are  old  age,  gout,  alcoholism, 
syphilis,  and  rheumatism. 


192         DISEASES   OF   THE    CIRCULATORY  SYSTEM. 

Symptoms  of  Fatty  Infiltration. — In  fatty  infiltration 
symptoms  are  not  marked  unless  the  muscle-fibers  them- 
selves are  affected.  It  may  be  suspected  in  an  obese  sub- 
ject, when  the  only  symptoms  present  are  dyspnea  on 
exertion,  palpitation,  weak  heart-sounds,  and  a  feeble  but 
regular  pulse. 

Symptoms  of  Fatty  Degeneration  and  of  Fibroid 
Induration. — These  two  conditions  cannot  be  differentiated 
clinically.  The  symptoms  are  very  variable.  There  is  often  a 
sense  of  oppression  or  discomfort  in  the  region  of  the  heart. 
Attacks  of  angina  pectoris  may  occur.  Dyspnea  is  rarely 
absent.  Toward  the  end  Cheyne-Stokes  breathing  may  de- 
velop. The  pulse  is  usually  weak  and  irregidar^  both  in 
force  and  in  rhythm  ;  sometimes  it  is  intermittent,  and  occa- 
sionally it  is  extremely  slow  (40  or  50  a  minute).  The  first 
sound  of  the  heart  is  feeble  and  muffled ;  the  second  aortic 
sound  is  often  relatively  accentuated.  The  heart  is  not  neces- 
sarily enlarged.  There  may  be  no  murmurs,  but  a  systolic 
murmur  is  often  heard  at  the  apex  in  consequence  of  relaxa- 
tion of  the  mitral  sphincter.  There  may  be  edema  of  the  feet, 
and  even  anasarca.  Progressive  weakness  and  pallor  often 
develop  from  increased  venous  tension  and  interference  with 
absorption.  Attacks  of  asystole  (orthopnea,  cyanosis,  pul- 
monary edema,  and  delirium  cordis)  are  occasionally  ob- 
served. In  rare  instances  the  Adams-Stokes  syndrome  (infre- 
quency  of  pulse  with  syncopal,  epileptiform,  or  vertiginous 
attacks)  is  present. 

The  history,  age  of  the  patieitt,  and  condition  of  the  arteries 
must  also  be  considered  in  making  the  diagnosis. 

Prognosis. — Serious.  Sudden  death  may  occur  at  any 
time. 

Treatment  of  Fatty  and  Fibroid  Heart. — Laborious 
work,  mental  strain,  and  excitement  should  be  avoided,  as  far 
as  possible.  The  diet  should  be  simple  and  easily  digestible. 
When  the  pathologic  changes  are  not  far  advanced,  and  par- 
ticularly if  they  consist  in  fatty  overgrowth  rather  than  in  de- 
generation of  the  muscle-fibers,  graduated  exercise,  coupled 
with  warm  saline  baths,  as  in  the  well-known  Nauheim  treat- 
ment, may  be  very  efficacious.   Constipation  must  be  relieved. 


ANGINA   PECTORIS.  1 93 

As  to  Special  treatment,  strychnin  (-^^  ^^  3V  g^^^"  thrice 
daily)  is  the  most  generally  useful  drug.  When  there  is 
anemia,  iron  and  arsenic  are  excellent  adjuvants.  Nitrites 
are  beneficial  in  cases  with  high  arterial  tension,  anginoid 
pains,  or  cardiac  asthma.  Digitalis  is  serviceable  in  some 
cases ;  it  should  be  given  cautiously,  however,  and  in 
small  doses. 

ANGINA  PECTORIS* 

(Neuralgia  of  the  Heart;  Stenocardia.) 

Definition. — A  symptomatic  affection  most  commonly 
associated  with  occlusion  of  the  coronary  arteries  and  de- 
generation of  the  myocardium,  and  characterized  by  severe 
paroxysmal  pain  in  the  region  of  the  heart  and  a  sense  of 
imminent  death. 

Btiology. — It  usually  develops  after  middle  life,  and  is 
very  much  more  common  in  men  than  in  women.  The  pre- 
disposing causes  are  those  of  arteriosclerosis — i.  e.,  alcohol- 
ism, gout,  and  syphilis.  In  some  instances  an  hereditary 
tendency  has  been  noted,  and  not  infrequently  the  attacks 
have  been  preceded  by  prolonged  mental  anxiety. 

A  false  angina  (^pseudo-angina  pectoris)  is  sometimes  asso- 
ciated with  hysteria,  or  the  excessive  use  of  tobacco. 

Pathology. — Obstruction  of  the  coronary  arteries  from 
atheroma,  thrombosis,  or  embolism,  with  resultant  degenera- 
tion of  the  myocardium,  is  the  condition  usually  found  after 
death.  Occasionally,  typical  attacks  occur  in  lesions  of  the 
aortic  valve,  especially  insufficiency,  and  in  aortic  aneurysm. 

Symptoms. — The  attacks  are  usually  excited  by  strong 
emotion,  muscular  effort,  or  flatulent  indigestion,  and  are 
characterized  by  agonizing  pain,  radiating  from  the  heart 
to  the  shoulder  and  arm  (usually  the  left),  a  sense  of  im- 
pending death,  immobility  of  the  body,  dyspnea,  and  a  pale, 
anxious  face.  The  pulse  is  very  variable.  The  attacks  last 
from  a  few  seconds  to  several  minutes.  Death  may  occur 
in  the  first  attack,  or  there  may  be  recurring  attacks  over  a 
period  of  many  years. 

Hysteric  Angina. — This  neurosis  is  seen  chiefly  in  women, 
whereas  true  angina  is  very  rare  in  women ;  there  is  no  evi- 
ls 


194         DISEASES   OF   THE    CIRCULATORY  SYSTEM. 

dence  of  organic  heart  disease ;  the  attack  is  longer  in 
duration  ;  there  is  no  immobility  of  the  body  ;  emotional 
outbreaks,  such  as  moaning  and  crying,  are  common,  and 
vasomotor  phenomena  are  often  pronounced. 

Gastralgia. — The  pain  is  apt  to  appear  when  the  stomach 
is  empty,  and  is  relieved  by  stimulating  food ;  it  does  not 
radiate  to  the  shoulder  and  arm ;  there  is  no  sense  of  im- 
pending death,  no  fixation  of  the  body,  and  no  evidence  of 
structural  heart  disease. 

Prognosis. — Grave.  Sudden  death  may  occur  at  any 
time.     In  false  angina  the  prognosis  is  favorable. 

Treatment. — The  general  treatment  is  that  of  chronic 
myocardial  disease.  The  most  valuable  special  remedies,  in 
the  order  of  their  efficacy,  are  the  nitrites,  iodids,  and  arsenic. 

The  Attack. — No  drug  is  so  generally  useful  as  amyl  ni- 
trite (3  to  5  minims  on  a  handkerchief).  Marked  flatulency 
should  be  met  by  the  prompt  administration  of  Hoffmann's 
anodyne  or  spirit  of  mint.  When  the  attacks  are  severe  and 
prolonged,  morphin  {\  to  \  grain)  should  be  given  hypoder- 
mically.  When  these  remedies  fail,  recourse  should  be  had 
to  chloroform  inhalations.  The  application  of  heat  to  the 
precordium  is  useful.  Cardiac  depression  following  the 
seizures  should  be*  combated  by  strychnin,  ammonia,  cam- 
phor, or  ether. 

DISEASES   OF  THE  ARTERIES. 
ANEURYSM  OF  THE  AORTA* 

Definition. — A  more  or  less  localized  dilatation  of  the 
aorta. 

!^tiolog^. — The  predisposing  causes  are  those  of  arterio- 
sclerosis— syphilis,  alcoholism,  gout,  rheumatism,  lead- 
poisoning,  and  nephritis.  Of  these,  syphilis  is  by  far  the 
most  potent  factor.  Immoderate  physical  exertion  is  the 
most  common  exciting  cause.  More  than  80  per  cent,  of 
all  cases  occur  in  males.  It  is  most  frequent  between  the 
ages  of  thirty  and  fifty. 

Pathology. — Aneurysms  are  divided,  according  to  shape, 


ANEUFYSM   OF   THE   AORTA.  1 95 

xnio  fusiform,  saccular,  and  cylindric  forms.  Rupture  of  the 
intima,  with  the  passage  of  blood  between  the  outer  tunics, 
constitutes  a  dissecting  aneurysm.  A  false  aneurysm  is  one 
in  which  all  the  tunics  are  ruptured  and  the  extravasated 
blood  is  circumscribed  by  the  surrounding  tissues. 

The  adventitia  and  intima  are  much  thickened,  while  the 
media  is  thinned  or  deficient.  Fibrinous  deposits  are  usually 
found  in  the  interior  of  the  sac,  especially  in  the  saccular  and 
fusiform  varieties. 

The  arch  of  the  aorta  is  the  most  common  seat.  About  5 
per  cent,  of  aortic  aneurysms  are  abdominal. 

THORACIC  ANEURYSM. 

Physical  Signs. — Inspection  may  reveal  a  circum- 
scribed bulging  and  an  abnormal  area  of  pulsation.  Dilata- 
tion of  the  superficial  veins  may  also  be  noted,  and  in 
advanced  cases  the  skin  over  the  prominence  may  be  red 
and  glossy. 

Palpation. — This  may  detect  an  expansile  pulsation,  a 
systolic  thrill,  and  a  diastolic  shock  from  the  recoil  of  the 
blood  in  the  sac. 

In  aneurysm  of  the  transverse  arch  a  downward  tug  of 
the  trachea  is  sometimes  felt  when  the  head  is  thrown  back 
and  the  cricoid  cartilage  is  grasped  between  the  fingers  and 
thumb. 

Percussion  may  reveal  an  abnormal  area  of  dulness  with 
increased  resistance. 

Auscultation. — Unless  the  sac  contains  too  much  fibrin, 
the  ear  may  detect  marked  accentuation  of  the  diastolic 
sound  and  a  systolic  murmur  or  bruit. 

Radioscopy  may  demonstrate  a  shadow  corresponding  to 
the  location  of  the  aneurysmal  sac. 

Pulse. — There  may  be  inequality  of  the  radial  pulses, 
owing  to  partial  blocking  of  a  main  arterial  branch  or  to 
pressure  on  the  innominate  or  one  of  the  subclavian  arteries 
by  the  sac  itself 

Pressure  Effects. — Dyspnea  with  stridulous  inspiration  may 
result  from  pressure  on  the  trachea  or  a  bronchus.     Parox- 


196         DISEASES   OF   THE    CIRCULATORY  SYSTEM. 

y Sinai  croupy  cough  may  be  excited  by  pressure  on  the 
trachea  or  recurrent  laryngeal  nerve.  Aphonia  may  also 
result  from  pressure  on  the  recurrent  laryngeal  nerve. 
Dysphagia  may  result  from  pressure  on  the  esophagus. 
Pain  of  a  boring  or  lancinating  character  may  arise  from 
pressure  on  neighboring  nerve-trunks  or  bones.  Dilatation 
or  contraction  of  one  pupil  and  uyiilateral  sweating  may  be 
excited  by  pressure  on  the  sympathetic. 

Edema  and  cyanosis  of  the  one  arm  and  shoulder  may 
follow  pressure  on  the  large  venous  trunks. 

Diagnosis. — Mediastinal  tumor  may  simulate  aneurysm, 
but  in  the  former  the  pulsation  is  not  expansile,  there  is  no 
diastolic  shock,  the  tracheal  tug  is  usually  absent,  and  there 
may  be  cachexia,  enlargement  of  superficial  glands,  and 
leukocytosis. 

Pulsating  Empyema. — A  left-sided  purulent  effusion  may 
transmit  a  cardiac  pulsation,  but  there  is  no  diastolic  shock, 
no  thrill,  and  no  murmur.  The  history,  moreover,  will 
usually  suggest  pleurisy. 

Aortic  Stenosis. — In  this  condition  there  are  no  evidences 
of  a  tumor,  no  pressure  symptoms,  and  no  changes  in  the 
pulses. 

Prognosis. — Grave.  Death  usually  occurs  in  from  one 
to  two  years  from  rupture,  asphyxia,  exhaustion,  cerebral 
embolism,  or  inflammation  of  a  lung  ('*  aneurysmal  phthisis  "). 
Rupture  may  take  place  into  the  trachea,  a  bronchus,  the 
esophagus,  lung,  pleura,  or  pericardium,  or  externally.  In 
rare  instances  recovery  follows  from  clot-formation. 

Treatment. — The  treatment  commonly  employed  is  a 
modification  of  Tufnell's  method,  and  consists  in  absolute 
rest  in  bed  for  a  period  of  six  or  eight  weeks,  a  compara- 
tively dry  diet,  and  the  administration  of  potassium  iodid 
(10  to  20  grains  thrice  daily).  For  severe  pain  the  most 
effective  measures  are  the  application  of  an  ice-bag  and  the 
administration  of  nitroglycerin  or  morphin.  When  there  is 
marked  dyspnea  with  cyanosis,  venesection  may  afford  prompt 
relief  Attempts  have  been  made  to  favor  coagulation  by 
injecting  gelatin  (lOO  c.c.  of  a  5  per  cent,  sterilized  solution) 
subcutaneously,  or  by  inserting  into  the  sac  fine  gold  wire 


A  R  TERIOSCL  ER  OS  IS.  1 97 

and  passing  through    the  wire  a  strong  galvanic   current 
(Moore-Corradi  treatment). 

ANEURYSM  OF  THE  ABDOMINAL  AORTA, 

Seat. — It  is  most  frequently  located  near  the  celiac  axis. 

Symptoms. — It  may  be  recognized  by  sharp  pain  in  the 
back,  radiating  along  the  spinal  nerves,  by  a  delay  in  the 
femoral  pulse,  by  gastro-intestinal  symptoms,  and  by  phy- 
sical signs  similar  to  those  of  thoracic  aneurysm. 

Diagnosis. — An  abdominal  tumor  may  receive  a  pulsa- 
tion from  the  aorta  and  simulate  aneurysm,  but  in  the 
former  the  pulsation  is  not  expansile,  and  is  frequently  lost 
when  the  patient  is  placed  in  the  knee-breast  posture. 

Expansile  Abdominal  Aorta. — This  is  most  frequently  seen 
in  women,  in  whom  abdominal  aneurysm  is  very  rare ;  the 
pulsation  is  often  paroxysmal ;  there  is  no  distinct  tumor, 
and  there  are  no  pressure  symptoms. 

Prognosis. — Very  grave.  Death  usually  results  from 
rupture.  Occasionally  the  fatal  issue  is  effected  through 
erosion  of  the  vertebrae  and  paraplegia,  or  through  embol- 
ism of  the  superior  mesenteric  artery. 

Treatment. — Same  as  in  thoracic  aneurysm. 

ARTERIOSCLEROSIS 

(Atheroma;  Chronic  Endarteritis.) 

Definition. — A  circumscribed  or  diffuse  thickening  of 
the  arterial  walls,  especially  of  the  intima,  secondary  to  cer- 
tain degenerative  changes  in  the  media. 

^  ^tiolog^y. — It  is  a  natural  accompaniment  of  old  age. 
The  causes  that  favor  its  early  development  are  alcoholism, 
syphilis,  gout,  Bright's  disease,  rheumatism,  chronic  lead- 
poisoning,  and  excessive  muscular  strain. 

Pathology. — The  arteries  are  thickened,  tortuous,  and 
rigid.  The  intima  of  the  large  vessels  reveals  roughened 
and  opaque  areas  that  may  be  the  seat  of  calcareous  de- 
posits. In  extreme  cases  there  may  be  spots  of  necrotic 
softening  in  the  subendothelial  tissue,  forming  so-called 
"  atheromatous  abscesses." 


ipS         DISEASES   OF  THE    CIRCULATORY  SYSTEM. 

Microscopically,  the  muscular  fibers  of  the  media  are  atro- 
phied and  the  seat  of  fatty  degeneration  or  calcification.  In 
the  intima  there  is  marked  hyperplasia  of  the  subendothe- 
lial  connective  tissue,  the  cells  of  which  may  be  the  seat  of 
hyaline,  fatty,  or  calcareous  degeneration.  The  adventitia  is 
also  the  seat  of  connective-tissue  overgrowth. 

Symptoms. — These  vary  with  extent  and  distribution  of 
the  sclerosis.  When  the  process  is  general,  it  may  be  rec- 
ognized by  rigidity  of  the  peripheral  vessels,  a  sluggish, 
high-tension  pulse,  accentuation  of  the  second  aortic  sound, 
and  enlargement  of  the  left  ventricle. 

When  the  coronary  arteries  are  especially  involved,  the 
symptoms  of  chronic  myocardial  disease  appear.  When  the 
renal  vessels  are  especially  affected,  there  may  be  symptoms 
of  chronic  interstitial  nephritis.  Involvement  of  the  cerebral 
arteries  may  be  indicated  by  headache,  vertigo,  insomnia, 
mental  sluggishness,  and,  perhaps,  transient  paralysis. 

Sequels. — Cerebral  hemorrhage  or  thrombosis,  chronic 
myocardial  disease,  angina  pectoris,  interstitial  nephritis, 
aneurysm,  and  gangrene  of  the  extremities. 

Treatment. — Treatment  should  be  directed  to  the  under- 
lying diathesis.  Alcohol  should  be  forbidden.  Overexer- 
tion, both  mental  and  physical,  is  injurious.  Gentle  exercise 
in  the  open  air,  however,  may  be  recommended.  Heavy 
feeding  must  be  restricted.  The  periodic  use  of  mild  mer- 
curial or  saline  aperients  is  very  beneficial.  Potassium  iodid 
and  the  nitrites  are  often  useful  when  the  blood-pressure 
becomes  too  high. 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


THE  NOSE. 


Movement  of  the  Alse  Nasi  during  Respiration. — 

Playing  of  the  alae  is  occasionally  noted  in  health,  but  it  is 
generally  an  indication  of  some  obstruction  to  the  entrance 
of  air.  It  is  frequently  observed  in  spasmodic  croup,  true 
croup,  laryngeal  edema,  capillary  bronchitis,  and  pneumonia. 

Nasal  Discharge.  —  Temporary  "  running  from  the 
nose  "  is  a  symptom  of  acute  coryza,  measles,  hay-fever, 
diphtheria,  and  influenza.  An  offensive  discharge  should 
suggest  nasal  diphtheria  or  the  impaction  of  a  foreign  body. 

Chronic  discharge  occurs  in  chronic  rhinitis.  In  infants, 
chronic  nasal  discharge  with  mouth-breathing  ("  snuffles  ") 
is  very  suggestive  of  hereditary  syphilis. 

The  Sense  of  Smell. — This  is  tested  by  holding  odor- 
iferous substances  before  one  nostril  at  a  time  while  the  other 
is  closed.  Pungent  vapors  should  be  avoided,  as  the  irrita- 
tion which  they  excite,  and  not  their  odor,  may  lead  to  their 
recognition. 

The  sefise  of  smell  may  be  impaired  <?r/^5"/ (anosmia)  from  : 

1.  Rhinitis  or  morbid  growths. 

2.  Affections  of  the  anterior  part  of  the  brain,  involving 
the  olfactory  nerves  or  bulbs — as  injury,  tumor,  meningitis. 

3.  Lesions  of  the  olfactory  centers  (temporosphenoidal 
lobe). 

Paralysis  of  the  trigeminal  nerve  (by  inducing  dryness  of 
the  mucous  membrane). 

Extreme  acuteiiess  of  the  sejise  of  smell  (hyperosmia)  and 
perversions  of  the  sense  of  smell  (parosmia)  are  sometimes 
observed  in  neurasthenia,  hysteria,  and  insanity. 

199 


200        DISEASES   OE   THE   RESPIRATORY  SYSTEM. 

^pistaxis. — Hemorrhage  from  the  nose  occurs  under 
the  following  conditions  :  (i)  Traumatism  ;  (2)  inflammation 
or  ulceration ;  (3)  new  growths ;  (4)  cerebral  congestion ; 
(5)  engorgement  from  chronic  heart  or  liver  disease  ;  (6) 
blood  dyscrasia,  as  in  hemophilia,  purpura,  scurvy,  pernic- 
ious anemia,  etc. ;  (7)  onset  of  fevers,  especially  typhoid ;  (8)  in 
rarefied  atmosphere,  as  in  mountain-climbing ;  (9)  vicarious 
menstruation  (rare). 

THE  LARYNX. 

Spasm  of  the  laryngeal  adductors  is  characterized 
by  intense  dyspnea  and  occurs  in  spasmodic  croup;  in  true 
croup;  in  ulceration  of  the  larynx;  in  laryngismus  stridu- 
lus ;  in  whooping-cough ;  in  tetany  ;  in  hysteria  ;  in  hydro- 
phobia ;  in  the  laryngeal  crisis  of  locomotor  ataxia ;  when 
foreign  bodies  have  lodged  in  the  larynx;  and  when  aneu- 
rysms or  mediastinal  tumors  press  on  the  recurrent  laryn- 
geal nerve  and  irritate  it. 

Aphonia  or  loss  of  voice  may  be  due  to  :  ( i )  Organic 
disease  of  the  larynx — inflammation,  neoplasms,  cicatricial 
stenosis.  (2)  Centric  paralysis  of  the  recurrent  laryngeal 
nerves,  as  in  bulbar  palsy.  (3)  Peripheral  paralysis  of  the 
recurrent  laryngeal  nerves  caused  by  pressure  of  an  aneu- 
rysm, mediastinal  tumor,  or  pericardial  effusion.  (4)  Hys- 
teria. (5)  The  lodgement  of  foreign  bodies.  (6)  Prolonged 
use  of  the  voice. 

RESPIRATION. 

Dyspnea. — Dyspnea  implies  difficult  breathing,  with  or 
without  an  increase  in  the  number  of  respirations.  Dysp- 
nea which  is  so  severe  as  to  necessitate  a  sitting  posture  is 
termed  orthopnea.  Dyspnea  may  occur  on  inspiration,  ex- 
piration, or  both. 

Its  chief  causes  are:  (i)  Obstruction  in  the  larynx  from 
spasm,  paralysis,  false  membrane,  edema,  or  a  foreign  body. 

(2)  Pressure  of  an  aneurysm,  tumor,  or  large  glands  upon 
the  trachea,  a  bronchus,  or  the  recurrent  laryngeal   nerve. 

(3)  Asthma.     (4)  Diseases  of  the  lungs,  as  pneumonia,  em- 


respiration:  201 

physema,  edema,  phthisis,  abscess,  and  gangrene.  (5) 
Pleural  effusions.  (6)  Cardiac  disease.  (7)  Paralysis  of  the 
muscles  of  respiration.  (8)  Abdominal  distention.  (9) 
Anemia. 

Inspiratory  dyspnea  is  frequently  seen  with  tumors  or 
foreign  bodies  in  the  larynx. 

Expiratory  dyspnea  is  noted  in  emphysema  and  occasion- 
ally in  movable  tumors  situated  below  the  glottis.  In 
asthma,  also,  the  dyspnea  may  be  largely  inspiratory. 

The  Number  of  Respirations  a  Minute. — In  the 
healthy  male  adult  the  number  of  respirations  is  about  18 
a  minute.  In  women  and  children  breathing  is  somewhat 
more  rapid.  The  ratio  between  respirations  and  pulse-beats 
is  as  I  is  to  4  or  4.5. 

Rapid  respirations  are  noted  in  excitement ;  in  pyrexia ;  in 
inflammatory  diseases  of  the  lungs  ;  in  anemia ;  in  certain 
affections  involving  the  base  of  the  brain ;  in  poisoning  from 
certain  drugs  that  affect  the  respiratory  center ;  in  hysteria ; 
in  painful  affections  of  the  respiratory  muscles,  as  pleuro- 
dynia and  pleurisy. 

Infrequent  respirations  are  observed  in  certain  diseases  of 
the  brain,  as  meningitis,  tumor,  apoplexy  ;  in  advanced  fatty 
degeneration  of  the  heart ;  in  certain  forms  of  coma,  par- 
ticularly uremic  and  diabetic ;  in  poisoning  with  certain 
drugs,  especially  opium ;  in  obstruction  to  the  air-passages, 
as  in  asthma  and  in  laryngeal  spasm. 

Cheyne-Stokes,  or  Tidal- wave  Breathing. — In  this 
type  the  respirations  gradually  increase  in  rapidity  and 
volume  until  they  reach  a  climax,  then  gradually  subside, 
and  finally  cease  entirely  for  from  five  to  fifty  seconds,  when 
they  begin  again.  It  depends  on  some  disturbance  of  the 
respiratory  center  the  exact  nature  of  which  is  still  undeter- 
mined. It  is  usually  a  forerunner  of  death,  but  cases  have 
been  reported  in  which  it  has  lasted  several  months. 

Its  chief  causes  are  :  (i)  Certain  cerebral  diseases,  as  apo- 
plexy, meningitis,  and  tumor.  (2)  Advanced  cardiac  dis- 
ease, especially  fatty  degeneration.  (3)  Certain  forms  of 
coma,  especially  that  produced  by  uremia,  opium-poisoning, 
and  sunstroke. 


202         DISEASES   OF   THE   RESPIRATORY  SYSTEM. 

COUGH, 

Cough  may  be  induced  by:  (i)  Most  organic  diseases  of 
the  pharynx,  larynx,  bronchi,  and  lungs.  (2)  Foreign 
bodies  in  the  air-passages.  (3)  Certain  infections  which  are 
associated  with  catarrh,  such  as  typhoid  fever,  measles, 
whooping-cough,  and  influenza.  (4)  Inhalation  of  irritant 
dusts  or  vapors.  (5)  Reflex  irritation,  as  from  pressure  on 
the  recurrent  laryngeal  nerve  or  from  disease  of  the  abdomi- 
nal organs.     (6)  Hysteria. 

I/aryngeal  Cough. — This  cough  has  a  hard,  metallic, 
ringing  intonation,  and  has  been  termed  "  croupy."  It  is 
observed  in  laryngitis  ;  in  whooping-cough ;  in  tuberculosis 
and  syphilis  of  the  larynx ;  when  a  foreign  body  is  lodged 
in  the  larynx ;  when  the  recurrent  laryngeal  nerve  is  irri- 
tated by  pressure  of  a  tumor  or  aneurysm  ;  and  in  hysteria. 

Dry  Cough. — Cough  without  expectoration  is  especially 
observed  in  the  beginning  of  inflammatory  diseases  of  the 
bronchi  and  lungs ;  in  pleurisy ;  in  most  chest  diseases  of 
early  childhood  ;  and  in  reflex  irritation  of  the  larynx. 

Moist  or  loose  cough  occurs  especially  in  bronchitis, 
bronchiectasis,  abscess  of  the  lung,  convalescent  pneumonia, 
and  phthisis. 

EXPECTORATION. 

Mucoid  sputum  is  noted  especially  in  the  beginning  of 
acute  bronchitis  ;  in  asthma ;  in  the  early  stage  of  pneumo- 
nia and  phthisis ;  and  in  pulmonary  edema.  In  edema  the 
sputum  is  very  frothy  and  watery. 

Mucopurulent  Sputum. — This  is  observed  in  subacute 
and  chronic  catarrhal  affections  of  the  lungs  and  bronchi, 
especially  in  subacute  and  chronic  bronchitis,  convalescent 
pneumonia,  and  phthisis. 

Purulent  Sputum. — Sputum  is  rarely  composed  of  pure 
pus.  Expectoration  almost  entirely  purulent  is  sometimes 
observed  in  bronchiectasis,  in  phthisis  with  cavities,  in  ab- 
scess of  the  lung,  and  when  an  empyema  ruptures  into  the 
lung. 

Prune-juice  sputum  is  tinged  with  altered  blood  so  as 
to  resemble  prune-juice.     It  results  from  retention  of  blood 


EXPECTORATION.  20  3 

in  the  lung,  and  is  observed  in  advanced  croupous  pneu- 
monia, especially  low  forms,  in  gangrene  of  the  lung,  and 
in  cancer  of  the  lung. 

Rusty  Sputum. — A  rusty  and  tenacious  sputum  is 
strongly  indicative  of  croupous  pneumonia. 

Currant -jelly  sputum  is  more  or  less  characteristic  of 
cancer  of  the  lung. 

Reddish-brown  sputum  (resembling  anchovy  sauce) 
containing  amebae  is  sometimes  observed  in  hepatopulmo- 
nary  abscesses. 

Sputum  containing  fibrous  shreds  is  observed  in 
membranous  croup,  in  diphtheria,  and  in  fibrinous  bron- 
chitis. 

Fetid  sputum  usually  results  from  bronchiectasis,  ad- 
vanced phthisis  with  cavities,  gangrene  of  the  lung,  and 
abscess  of  the  lung. 

Such  sputum,  when  allowed  to  stand  in  a  conic  glass, 
settles  in  three  layers :  an  upper  layer  of  dirty  froth,  a 
middle  layer  of  turbid  mucus  in  which  are  suspended  puru- 
lent strings,  and  a  bottom  layer  of  decomposed  pus. 

Nummular  sputum  is  sputum  occurring  in  round,  flat, 
coin-shaped  masses,  which  sink  in  water.  Expectoration 
of  this  character  is  seen  in  advanced  phthisis  and  occasion- 
ally in  bronchiectasis. 

The  Microscopy  of  Sputum. — Elastic  fibers  are  found 
in  the  sputum  in  phthisis,  abscess,  gangrene  of  the  lungs, 
and  in  some  cases  of  bronchiectasis. 

The  Detection  of  Elastic  Fibers. — Place  the  sputum  which 
has  collected  during  the  night  in  a  glass  beaker,  and  add  to 
it  an  equal  volume  of  a  solution  of  caustic  soda  (20  grains 
to  the  ounce),  and  boil  over  a  spirit-lamp,  stirring  it  occa- 
sionally with  a  glass  rod.  As  soon  as  it  boils,  pour  into  a 
conic  glass,  and  add  four  or  five  times  the  amount  of  cold 
distilled  water.  Allow  the  mixture  to  stand  for  two  to 
three  hours,  and  examine  the  sediment  as  for  tube-casts 
(Fenwick). 

Spirals  of  Mucin. — Tightly  coiled  spirals  of  mucin,  which 
probably  represent  molds  of  the  fine  bronchioles,  were  first 
pointed    out   by    Curschmann    in    the    sputum    of  asthma. 


204        DISEASES   OF  THE  RESPIRATORY  SYSTEM. 

They  have  also  been  observed  in  the  sputum  of  croupous 
pneumonia. 

Charcot-Leyden  Crystals. — These  are  small  transparent 
octahedral  crystals,  similar  to  those  found  in  the  blood  in 
leukemia.  They  are  observed  especially  in  the  sputum  of 
asthma.  They  have  also  been  noted  in  phthisis,  in  fibrin- 
ous bronchitis,  and  in  acute  bronchitis. 

Crystals  of  Fatty  Acids. — These  occur  as  fine  needles, 
singly  or  in  bundles,  and  are  often  sharply  curved  near 
their  extremities.  They  are  observed  in  the  sputurrl  of 
chronic  bronchitis,  of  abscess,  and  of  gangrene  of  the 
lungs. 

Crystals  of  Hematoidin. — These  occur  as  small  yellow 
needles,  rhombic  plates  or  tufts,  and  are  found  in  sputa 
which  contain  altered  blood.  They  may  be  observed  in 
abscess,  gangrene,  and  cancer  of  the  lungs. 

Tubercle  Bacilli. — The  presence  of  tubercle  bacilli  in  the 
sputum  is  an  absolute  proof  of  tuberculosis,  but  a  failure  to 
detect  them  after  one  or  two  examinations  is  no  proof 
against  phthisis.  .  The  bacillus  is  a  fine  rod,  in  length  about 
half  the  diameter  of  a  red  blood-corpuscle,  and  often  slightly 
bent  and  beaded.  Its  detection  depends  on  its  power,  when 
stained,  of  resisting  the  bleaching  effect  of  acids.  To  view 
it  successfully,  a  -^  inch  oil-immersion  lens  is  required. 

Gabbetfs  Method. — Select  with  a  clean  needle  one  of  the 
minute  caseous  masses  contained  in  tuberculous  sputum, 
spread  it  out  in  a  very  thin  film  on  a  cover-glass,  dry  in  the 
air,  and  coagulate  the  albumin  in  the  bacteria  by  passing  the 
cover-glass,  smeared  side  up,  three  times  through  the  flame. 
Cover  the  specimen  with  Ziehl's  carbol-fuchsin  solution 
(fuchsin  I  ;  alcohol  lo;  5  per  cent,  aqueous  solution  of  car- 
bolic-acid crystals  90),  and  hold  the  cover-glass  over  the 
flame  for  a  few  minutes  at  such  a  distance  that  steam  is 
formed.  Wash  off  the  excess  of  stain  in  water,  and  coun- 
terstain  by  treating  the  preparation  for  thirty  seconds  with 
Gabbett's  solution  (methylene-blue  2;  sulphuric  acid  25; 
water  75).  Again  wash  in  water,  dry,  and  mount  in 
Canada  balsam.  The  tubercle  bacilli  will  appear  as  red 
rods  in  a  blue  field. 


PHYSICAL  EXAMINA  TION  OF  RESFIRA  TOR  V  ORGANS.    20$ 

PHYSICAL  EXAMINATION  OF  THE  RESPIRATORY 

ORGANS. 

Inspection. — Inspection  determines  the  shape  of  the 
chest,  any  unnatural  prominence  or  depression,  the  amount 
of  expansion,  and  any  inequahty  of  expansion. 


Fig.  io. — An  outline  of  the  normal  chest. 

Phthisinoid  Chest. — The  anteroposterior  diameter  is  short ; 
the  thorax  is  long  and  flat ;  the  ribs  are  oblique ;  the  scapulae 
are  prominent ;  the  spaces  above  and  below  the  clavicles  are 


Fig.  II. — Rachitic  chest. 


depressed ;  and  the  angle  formed  by  the  divergence  of  the 
costal  margins  from  the  sternum  is  very  acute. 

RacMtic  Chest. — This  may  resemble  the  former,  but  usually 
the  sides  are  considerably  flattened  and  the  sternum  promi- 


206        DISEASES   OF   THE   RESPIRATORY  SYSTEM. 

nent,  so  that  the  term  "  pigeon-breast "  has  been  applied  to 
this  particular  form.  The  sternal  ends  of  the  ribs  are  enlarged 
or  "  beaded,"  and  this  characteristic  has  given  rise  to  the 
term  "  rachitic  rosary."  There  is  often  a  circular  constric- 
tion of  the  thorax  at  the  level  of  the  xiphoid  cartilage  (Har- 
rison's groove). 

Emphysematous  Chest. — In  advanced  emphysema  the 
thorax  is  short  and  round ;  the  anteroposterior  diameter  is 
often  as  long  as  the  transverse ;  the  ribs  are  horizontal ;  the 
angle  formed  by  the  divergence  of  the  costal  margin  from 
the  sternum  is  very  obtuse  or  quite  obliterated.  The  term 
"  barrel-shaped  chest  "  is  applied  to  this  configuration. 


Fig.  12. — Emphysematous  chest. 

Local  Prominences  and  Depressions. — An  unnatural  promi- 
nence or  depression  is  often  observed  over  the  lower  part  of 
the  sternum,  and  is  generally  congenital.  The  term  "  funnel 
breast "  or  '*  shoemaker's  breast"  (because  it  may  result  from 
the  pressure  of  tools)  has  been  applied  to  the  sternal  depres- 
sion. 

A  U7iilateral  or  local  depression  may  be  dtie  to :  (i)  Chronic 
phthisis  ;  (2)  cirrhosis  of  the  lung ;  (3)  pleurisy  with  fibrous 
adhesions. 

A  unilateral  or  local  prominence  may  be  due  to:  (i) 
Pleurisy  with  effusion ;  (2)  pneumothorax,  hydrothorax, 
hemothorax;  (3)  an  aneurysm  or  tumor ;  (4)  compensatory 
emphysema,  resulting  from  impairment  of  the  opposite  lung; 


PHYSICAL  EXAMINATION  OF  RESPIRATORY  ORGANS.    20/ 

(5)  cardiac  enlargements  (left  side) ;  (6)  enlargements  of  the 
abdominal  organs,  especially  the  liver  and  spleen. 

Expansion. — In  women  and  in  children,  and  in  both  sexes 
during  sleep,  breathing  is  largely  thoracic  or  costal ;  in  men 
and  in  the  old  of  both  sexes  it  is  largely  abdominal  or  dia- 
phragmatic. 

Restricted  abdominal  breathing  is  observed  in  pregnancy, 
in  abdominal  tumors,  and  effusions  ;  in  peritonitis  ;  in  dia- 
phragmatic pleurisy;  in  paralysis  of  the  phrenic  nerve  from 
pressure  or  from  bulbar  disease ;  and  occasionally  in  the 
"  hysteric  abdomen." 

Dimifiished  expansion  of  one  side  is  observed  in  pleural 
effusions;  in  acute  pleurisy  (from  pain);  in  consolidation  of 
the  lung  from  tuberculosis,  pneumonia,  or  tumor;  in  occlu- 
sion of  a  bronchus  ;  and  in  marked  enlargement  of  the  liver 
or  spleen. 

hicreased  expansion  of  one  side  is  observed  in  compensa- 
tory emphysema. 

Litten's  Diaphragm  Phenomenon. — When  a  healthy  indi- 
vidual is  placed  in  a  horizontal  position  with  the  feet  toward 
the  window  and  all  cross-lights  are  excluded,  a  narrow 
shadow  may  be  seen  descending  between  the  sixth  and  the 
ninth  rib  in  each  axilla  during  full  inspiration.  It  is  due  to 
the  separation  of  the  diaphragmatic  pleura  from  the  costal 
pleura  during  the  inspiratory  descent  of  the  diaphragm. 
This  shadow  is  absent  in  pleural  effusion,  pneumonia  of  the 
lower  lobe,  well-developed  emphysema,  and  extensive  pleu- 
ritic adhesions.  As  it  is  present  in  enlargement  of  the  liver 
and  in  subphrenic  abscess,  it  often  aids  materially  in  deter- 
mining whether  disease  is  above  or  below  the  diaphragm. 

Palpation. — Palpation  serves  to  detect  any  thoracic  ten- 
derness, edema,  friction  fremitus,  or  rales,  and  to  determine 
the  vocal  fremitus  and  amount  of  expansion. 

Thoracic  tenderness  is  observed  in  pleurisy;  in  phthisis 
and  pneumonia  from  being  associated  with  pleurisy ;  in 
pleurodynia ;  in  intercostal  neuralgia  (confined  to  certain 
spots) ;  and  in  surgical  affections,  like  caries  and  fracture 
of  the  ribs ;  and  in  contusion  and  inflammation  of  the 
parietes. 


208        DISEASES   OF  THE  RESPIRATORY  SYSTEM. 

Edema  of  the  chest-walls  is  recognized  by  "  pitting  "  when 
pressure  is  made  with  the  finger.  It  may  be  observed  in 
empyema ;  in  deep-seated  abscesses  of  the  parietes ;  after 
the  application  of  a  bhster ;  and  in  general  dropsy. 

Friction  Fremitus  and  Rales. — The  friction-rub  of  pleu- 
risy and  harsh,  sonorous  rales  can  sometimes  be  detected 
by  palpation. 

Vocal  fremitus  is  the  sense  of  vibration  imparted  by  the 
voice  to  the  palpating  hand. 

In  determining  the  vocal  fremitus  observe  the  following 
precautions  :  Palpate  symmetric  parts  of  the  chest ;  make 
firm  pressure ;  when  comparing,  use  the  same  pressure  on 
the  two  sides  ;  apply  the  hands  as  nearly  parallel  to  the  ribs 
as  possible ;  and  remember  that  the  fremitus  is  normally 
stronger  over  the  right  chest  than  the  left. 

The  fremitus  is  usually  slight  in  women  and  in  children, 
and  in  men  with  thick  chest-walls  and  a  weak  voice. 

Vocal  fremitus  is  abnormally  increased  when  the  lung  is 
consolidated  and  the  bronchi  are  patulous,  as  in — ^(i) 
Tuberculosis ;  (2)  croupous  pneumonia ;  (3)  bronchopneu- 
monia. 

Vocal  fremitus  is  decreased  or  absent  \w — -.(i)  Pleural  effu- 
sions— air,  serum,  pus,  blood,  or  lymph  ;  (2)  emphysema  ; 
(3)  pulmonary  collapse  from  an  obstructed  bronchus ;  (4) 
pulmonary  edema ;  (5)  morbid  growths  of  the  lung. 

Percussion. — Percussion  determines  resonance,  pitch, 
and  resistance. 

hmnediate  percussion  is  performed  by  striking  the  chest 
directly  with  the  fingers.  It  is  not  often  employed,  except 
over  the  clavicles,  where  the  bones  themselves  act  as  plex- 
imeters. 

Mediate  percussion  is  performed  by  using  the  fingers  of 
one  hand  as  a  plexor  and  those  of  the  opposite  hand  as  a 
pleximeter;  or  by  using  a  piece  of  ivory,  glass,  or  hard 
rubber  as  a  pleximeter,  and  a  small  hammer  as  a  plexor. 

The  use  of  the  fingers  alone  is  preferable,  for  only  in  this 
way  can  resistance  be  determined. 

In  percussion  the  following  precautions  should  be  ob- 
served :  Place  the  finger  that  is  being  used  as  a  pleximeter 


PHYSICAL  EXAMINATION  OF  RESPIRATORY  ORGANS.    209 

firmly  against  the  chest,  and  preferably  parallel  to  the  ribs ; 
make  the  finger  that  is  used  as  plexor  strike  the  one  on  the 
chest  perpendicularly;  fix  the  forearm,  and  use  no  more 
force  than  can  be  obtained  from  a  gentle  swing  of  the  wrist. 
When  possible,  percuss  all  parts  of  the  chest  anteriorly  and 
posteriorly ;  percuss  both  in  inspiration  and  in  expiration. 
In  comparing  the  two  sides,  be  sure  to  percuss  symmetric 
parts. 

Normal  Resonance. — On  the  right  side,  pulmonary  reso- 
nance extends  from  a  half  inch  to  an  inch  above  the  clav- 
icle, downward  to  the  upper  border  of  the  sixth  rib  in  front, 
and  to  a  line  drawn  through  the  tenth  spinous  process 
posteriorly. 

On  the  left  side,  pulmonary  resonance  extends  from  a 
half  inch  to  an  inch  above  the  clavicle,  downward,  within 
the  mammary  line  to  the  third  rib,  outside  of  the  mammary 
line  to  the  tenth  rib,  and  posteriorly  to  a  line  drawn  through 
the  tenth  spinous  process. 

Traube's  Semilunar  Space. — This  is  a -tympanitic  area  at 
the  base  of  the  left  chest,  bounded  above  by  the  lung 
(sixth  rib),  on  the  right  by  the  liver,  and  on  the  left  by  the 
spleen.     It  is  obliterated  in  pleural  effusion  on  the  left  side. 

Hyperresonance  is  observed  in  the  following  conditions  : 
(l)  Pneumothorax.  (2)  Cayities — tuberculous  or  bronchi- 
ectatic.  (3)  Emphysema.  (4)  Lowered  pulmonary  ten- 
sion, as  above  a  pleural  effusion  or  consolidation,  and  in  the 
initial  stage  of  pneumonia  (Skoda's  resonance).  (5)  Flatu- 
lent distention  of  the  stomach  or  colon  (frequently  observed 
over  the  base  of  the  left  chest). 

Tympanitic  resonance  is  resonance  of  a  hollow,  drum-like 
character,  like  that  normally  obtained  by  percussing  the 
empty  stomach  or  the  colon.  It  is  elicited  over  the  chest 
in  pneumothorax  and  cavity-formation. 

The  cracked-pot  sound,  or  bruit  de  pot  fele,  is  a  modified 
tympany,  and  can  be  simulated  by  percussing  over  the 
cheek  when  the  mouth  is  partially  open.  It  may  be  nor- 
mally heard  over  the  chest  of  a  crying  infant  (Walshe).  In 
the  adult  it  usually  indicates  a  cavity  that  has  a  free  com- 
munication with  a  bronchus.     It  is  best  detected  by  keeping 

14 


2IO        DISEASES   OF   THE   RESPIRATORY  SYSTEM. 

the  ear  near  the  open  mouth  of  the  patient  while  percus- 


sing. 


Dulness  or  flatness  on  percussion  may  be  caused  by  the 
following  conditions:  (i)  Pleural  effusions  of  all  kinds,  ex- 
cept air;  (2)  consolidation  of  the  lung  from  tuberculosis  or 
pneumonia ;  (3)  collapse  of  the  lung ;  (4)  congestion  and 
edema  of  the  lung;  (5)  morbid  growths  in  the  lung;  (6) 
enlargement  of  the  liver  or  spleen  (at  the  bases). 

Pitch. — Pitch  of  the  note  depends  largely  upon  the  vol- 
ume of  air,  upon  the  tension  of  the  walls  of  the  cavity,  and 
upon  the  size  of  the  opening  that  communicates  with  the 
cavity.  The  less  the  air,  the  greater  the  tension,  and  the 
smaller  the  opening,  the  higher  will  be  the  pitch  of  the 
note.  It  is  obvious,  therefore,  that  conditions  that  are  asso- 
ciated with  hyperresonance  may  yield  either  a  high-  or  a 
low-pitched  note.  In  beginning  phthisical  consolidation 
the  note  over  the  affected  apex  is  higher  pitched ;  but  it 
must  be  borne  in  mind  that  normally  the  note  over  the  right 
apex  is  higher  pitched  than  that  over  the  left. 

Eesistance. — The  sense  of  resistance  appreciated  by  the 
percussing  finger  is  increased  in  proportion  as  the  air  in  the 
lung  is  decreased.  It  is  generally  more  marked  over  a  pleural 
effusion  than  over  a  consolidation  with  patulous  bronchi. 

Auscultation. — Auscultation  of  the  lungs  is  practised 
to  determine  the  character  of  the  respiratory  and  voice 
sounds,  and  to  detect  adventitious  sounds  like  rales. 

In  immediate  auscultation  the  ear  is  placed  directly  over 
the  chest,  only  a  soft  towel  intervening. 

In  mediate  auscultation  the  sounds  are  transmitted  through 
a  stethoscope,  which  should  be  applied  to  the  bare  chest. 

In  auscultation  observe  the  following  precautions :  Do 
not  exert  much  pressure  with  the  stethoscope.  When  the 
chest  is  covered  with  hair,  this  should  be  moistened,  other- 
wise it  is  likely  to  produce  crackHng  sounds  resembHng 
rales.  When  possible,  examine  carefully  all  parts  of  the 
chest,  anteriorly  and  posteriorly,  during  quiet  breathing, 
during  full  inspiration,  during  full  expiration,  and  after 
coughing.  Compare  carefully  the  sounds  elicited  over  sym- 
metric parts  of  the  chest. 


PHYSICAL  EXAMINA  TION  OF  R  ESP  IRA  TOR  V  ORGANS.    2  1 1 

Normal  Respiration. — Vesicular  breathing  is  heard  over 
the  body  of  the  lungs  and  is  characterized  by  a  soft,  breezy 
inspiratory  sound,  and  a  shorter,  lower  pitched,  less  intense 
expiratory  sound.  Normally,  the  expiratory  sound  is  not 
more  than  one-third  the  length  of  the  inspiratory  sound. 
Not  infrequently  expiration  is  wholly  inaudible.  Over  the 
trachea  and  main  bronchi  the  sounds  are  harsh  and  blowing, 
and  the  expiratory  sound  is  as  long  as  the  inspiratory  or 
slightly  longer  (bronchial  breathing). 

Modifications  of  the  Respiratory  Murmur. — Puerile  Breath- 
ing and  Exaggerated  BreatJiing. — Normal  breathing  in  chil- 
dren is  called  puerile  breathing.  Both  inspiration  and  ex- 
piration are  proportionately  increased  in  length  and  loudness. 
Exaggerated  breathing  has  the  same  characteristics  as  puerile 
breathing,  and  is  heard  after  exertion  and  over  the  whole  of 
one  lung  (compensatory  emphysema)  when  the  other  is 
disabled. 

Bro?ichial  or  Tubidar  Breathing. — This  is  harsh,  blowing 
breathing  with  prolonged,  accentuated  expiration.  The  ex- 
piration may  be  considerably  longer  than  the  inspiration, 
and  there  is  often  a  distinct  pause  between  the  two  sounds. 
Bronchial  breathing  is  heard  normally  over  the  trachea  and 
in  the  interscapular  space  over  the  large  bronchi,  and  ab- 
normally over  consolidated  lung,  when  the  bronchi  are  free. 
Thus,  it  may  be  heard  in  croupous  pneumonia,  broncho- 
pneumonia, tuberculosis  of  the  lung,  and  in  pleurisy  over 
the  compressed  lung. 

Bronchovesicidar  Breathing. — This  is  breathing  that  is 
neither  bronchial  nor  vesicular.  It  is  somewhat  harsh,  and 
expiration  is  slightly  prolonged  and  high  pitched.  Unlike 
puerile  or  exaggerated  breathing,  the  normal  ratio  of  in- 
spiration to  expiration  is  not  maintained — the  expiration  is 
not  relatively  but  actually  prolonged.  Bronchovesicular 
breathing  may  be  heard  when  the  lung  is  slightly  solidified, 
as  in  beginning  phthisis. 

Cavernous  or  Amphoric  Breathing. — This  resembles  bron- 
chial breathing,  but  the  sounds  have  a  hollow  character,  and 
the  pitch  of  the  expiration  is  lower  than  that  of  inspiration. 
It  may  be  imitated  by  blowing  over  the  mouth  of  an  empty  jar. 


212         DISEASES   OF   THE   RESPIRATORY  SYSTEM. 

Cavernous  breathing  may  be  heard  in  the  following  con- 
ditions :  (i)  Phthisical  or  bronchiectatic  cavities  ;  (2)  pneu- 
mothorax, when  the  opening  in  the  lung  is  patulous ;  (3) 
areas  of  consolidation  near  a  large  bronchus  ;  (4)  sometimes 
over  lung  compressed  by  a  moderate  effusion. 

The  Breathing  of  Emphysema. — This  is  weak  breathing, 
with  prolonged  low-pitched  or  inaudible  expiration. 

Cogged-wheel  or  Jerky  Breathing. — The  respiratory  mur- 
mur is  not  continuous,  but  is  broken  into  waves.  It  is  not 
indicative  of  any  special  disease,  but  it  is  frequently  observed 
in  hysteria,  pleurodynia,  bronchitis,  and  incipient  phthisis. 

Weak  or  Shallow  Breathing. — This  is  noted:  (i)  When 
the  chest-walls  are  thick;  (2)  in  the  old  and  feeble;  (3)  in 
emphysema ;  (4)  in  pleural  effusion ;  (5)  sometimes  in  in- 
cipient phthisis ;  (6)  in  painful  affections  oi  the  chest,  like 
pleurodynia  and  beginning  pleurisy ;  (7)  in  pulmonary 
edema. 

Vocal  Resonance. — This  is  the  confused  humming  sound 
heard  over  the  chest  when  the  patient  speaks.  It  is  modified 
by  the  same  conditions  that  modify  the  vocal  fremitus  (see 
p.  208). 

Bronchophony. — This  is  exaggerated  vocal  resonance.  It 
is  heard  normally  over  the  trachea,  and  abnormally  over 
consolidated  lung  (phthisis  and  pneumonia)  when  the  bronchi 
are  free,  over  lung  that  is  compressed  by  pleural  effusion, 
and  over  some  cavities. 

Pectoriloquy. — This  is  a  modification  of  vocal  resonance  in 
which  the  articulate  speech  is  heard  very  distinctly,  as  though 
coming  directly  from  the  chest  into  the  ear.  It  is  more  pro- 
nounced when  the  patient  whispers. 

Pectoriloquy  is  heard  over  :  (i)  Cavities  that  communicate 
with  a  bronchus  ;  (2)  areas  of  consolidation  in  the  neighbor- 
hood of  a  large  bronchus ;  (3)  pneumothorax,  when  the 
opening  in  the  lung  is  patulous ;  (4)  some  pleural  effusions. 

Egophony. — This  is  a  modification  of  bronchophony,  in 
which  the  sounds  have  a  trembUng  or  bleating  quality. 
It  is  usually  heard  over  slight  pleural  effusions  near  tlije 
upper  border  of  dulness,  especially  near  the  inferior  angle 
of  the  scapula. 


PHYSICAL  EXAMINA  TION  OF  RESPIRA  TOR  V  ORGANS.    2 1  3 

Adventitious  Sounds. — These  are  not  modifications  of  pre- 
existing sounds,  but  wholly  new  sounds  produced  in  the  lung 
or  pleura.  They  include  rales,  the  friction-sound,  metallic 
tinkling,  and  succussion-splash. 

Rales. — These  are  new  sounds  created  in  the  trachea, 
bronchi,  air-vesicles,  or  in  cavities.  They  may  be  due  to  the 
passage  of  air  through  liquid,  through  constricted  tubes,  or 
into  collapsed  air-vesicles. 

^     \  Sonorous. 
f  Subcrepitant. 


Moist  \  Bubbling. 
(  Gurgling. 
Vesicular  =  Crepitant. 

Dry  rales  are  probably  produced  by  the  passage  of  air 
over  very  viscid  secretion  in  the  tubes,  although  they  have 
been  ascribed  to  the  passage  of  air  through  bronchial  tubes 
that  are  narrowed  by  spasm  or  by  swelling  of  the  mucosa. 
They  are  heard  particularly  in  bronchitis  and  asthma.  Sibi- 
lant rales  are  whistling  and  high  pitched ;  sonorous  rales 
have  a  humming  quality  and  are  lower  pitched.  Dry  rales 
may  be  heard  on  inspiration,  expiration,  or  on  both. 

Moist  rales  result  from  the  presence  of  liquid  in  the  tubes  ; 
the  thinner  the  liquid  and  the  larger  the  tube,  the  coarser 
will  be  the  rales.  They  may  be  heard  on  inspiration,  ex- 
piration, or  on  both. 

Subcrepitant  or  crackling  rales  are  fine  moist  rales.  They 
are  heard  in  all  conditions  that  are  associated  with  liquid  in 
the  smaller  tubes,  as  bronchitis,  capillary  bronchitis,  pul- 
monary edema,  and  beginning  phthisis. 

Bubbling  rales  are  coarser  than  subcrepitant,  and  are  heard 
in  bronchitis,  in  resolving  croupous  pneumonia,  over  phthisi- 
cal deposits  that  are  softening,  and  over  small  cavities. 

Gurgling  rales  are  very  coarse,  and  resemble  the  bursting 
of  large  bubbles.  They  are  heard  over  large  cavities  that  con- 
tain fluid,  and  over  the  trachea  in  the  so-called  "death-rattle." 

Crepitant  Rales. — These  are  very  fine  rales,  usually  heard 
at  the  end  of  full  inspiration.  They  may  be  simulated  by 
rubbing  a  lock  of  hair  between  the  fingers.     They  have  been 


214        DISEASES   OE   THE   RESPIRATORY  SYSTEM. 

especially  associated  with  the  first  stage  of  croupous  pneu- 
monia, and  it  has  been  supposed  that  they  were  due  to  the 
forcible  separation  of  adherent  vesicular  walls.  Rales  very 
similar  to,  if  not  identical  with,  these  are  heard  in  pulmonary 
edema. 

Friction-sounds  are  produced  by  the  rubbing  together  of 
roughened  pleural  surfaces.  They  may  be  heard  both  in  in- 
spiration and  in  expiration,  and  often  resemble  subcrepitant 
rales,  but  they  are  more  superficial  and  localized  than  the 
latter,  and  are  not  modified  by  cough  or  deep  inspiration. 

A  roughened  pleura  in  the  neighborhood  of  the  heart 
may  produce  a  friction-sound  of  cardiac  rhythm,  and  one 
which  will  still  continue  when  the  breath  is  held ;  under 
other  conditions  pleural  friction-sounds  cease  when  respira- 
tion is  suspended. 

Metallic  Tinkling. — This  name  is  applied  to  silvery  or 
bell-like  sounds  that  are  heard  at  intervals  over  a  pneumo- 
hydrothorax  or  large  cavity.  Speaking,  coughing,  and  deep 
breathing  usually  induce  them.  Care  must  be  taken  not  to 
confound  them  with  similar  sounds  produced  by  the  presence 
of  Hquid  in  a  distended  stomach. 

Succussion-splasli  or  Hippocratic  Succussion. — This  is  a 
splashing  sound  produced  by  tiie  presence  of  air  and  Hquid 
in  the  chest.  It  may  be  elicited  by  gently  shaking  the 
patient  while  auscultating.  It  is  almost  pathognomonic  of 
hydropneumothorax  or  a  pyopneumothorax. 

A  similar  splashing  sound  is  often  heard  over  a  dilated 
stomach. 

Mensuration. — In  measuring  the  sides  of  the  chest  ob- 
serve the  following  precautions :  Measure  from  the  middle 
of  the  sternum  to  the  spinous  processes  ;  measure  both  sides 
after  inspiration  and  after  expiration ;  apply  the  tape  with 
equal  firmness  to  the  two  sides.  In  comparing,  measure 
corresponding  levels,  and  remember  that  the  right  side  is 
from  half  an  inch  to  an  inch  greater  in  circumference  than 
the  left. 

The  conditions  that  render  one  side  more  prominent  than 
the  other  have  already  been  considered. 

Radioscopy. — In  certain  conditions  of  the  chest  radios- 


COR  YZA.  2 1 5 

copy,  especially  the  fluoroscopic  screen,  furnishes  valuable 
information.  It  has  been  found  of  most  service  in  detecting 
aneurysms  and  in  determining  the  outlines  of  the  heart  in 
emphysema.  Some  observers  have  found  it  useful  in  detect- 
ing tuberculous  consolidation  before  any  other  signs  could  be 
elicited.  In  pleural  effusion  the  affected  side  is  dark,  the 
displacement  of  the  heart  is  well  shown,  and  the  diaphragm 
appears  flattened  and  depressed. 


DISEASES   OF  THE   NOSE  AND   LARYNX. 

CORYZA, 

(Acute  Rhinitis;   Cold  in  the  Head.) 

Definition. — An  acute  inflammation  of  the  nasal  cavities. 

!l^tiology. — Exposure  to  cold  and  to  wet,  especially  when 
the  body  is  overheated,  is  a  common  cause.  It  may  be  ex- 
cited by  the  inhalation  of  irritating  vapors  or  dust.  It  is  an 
expression  of  iodism.  It  is  a  symptom  of  certain  infectious 
diseases — especially  of  measles  and  influenza. 

Patliolog"y. — The  mucous  membrane  is  red  and  swollen. 
In  the  first  stage  there  is  no  secretion,  but  later  irritating, 
watery  mucus  flows  from  the  nose  and  excoriates  the  lip  ; 
this  in  time  is  followed  by  a  copious  mucopurulent  discharge. 

Symptoms. — The  disease  is  ushered  in  with  chilliness, 
malaise,  fulness  in  the  head,  and  sneezing.  The  nasal  cham- 
bers are  obstructed,  so  that  the  patient  is  obliged  to  breathe 
through  his  mouth.  At  first  there  is  no  secretion,  but  in 
twenty -four  or  forty-eight  hours  a  watery  discharge  is  estab- 
lished, which  later  becomes  mucopurulent.  SHght  fever  and 
its  associated  symptoms  are  commonly  present.  The  dura- 
tion is  from  a  few  days  to  two  weeks. 

Complications. — The  disease  is  not  infrequently  accom- 
panied with  conjunctivitis,  pharyngitis,  laryngitis,  and  catarrh 
of  the  Eustachian  tube  and  middle  ear  that  results  in  tem- 
porary deafness. 

Prognosis. — Favorable. 

Treatment. — When  the  patient  is  seen  at  the  outset  and 
is  willing  to  remain  indoors  for  twenty-four  hours,  a  hot  foot- 


2l6        DISEASES   OF  THE  RESPIRATORY  SYSTEM. 

bath,  with  a  full  dose  of  Dover's  powder,  followed  in  the  morn- 
ing by  a  Seidlitz  powder  or  other  saline  aperient,  often  gives 
excellent  results.  When  the  patient  is  fully  able  to  go  about, 
the  following  capsules  will  usually  afford  considerable  relief: 

JBt.    Pulveris  caniphorae .  gr.  vj 

Extract!  belladonnae 

Codeinse  sulphatis aa  gr.  iss 

Cinchoninse    sulphatis gr.  xij. — M. 

Pone  in  capsulas  No.  xij. 

SiG. — One  every  two  or  three  hours. 

Warm  Dobell's  solution  (see  p.  37)  or  warm  distilled  ex- 
tract of  witch-hazel  (diluted  with  i  part  of  water)  used  as  a 
spray  at  intervals,  and  followed  in  a  few  minutes  by  an  oily 
application  like  the  following,  generally  renders  satisfactory 
service : 

R.    Mentholis gr.  iij 

Olei  pini  pumilionis 11^  v 

Petrolati  hquidi q.  s.  adf^j. — M. 

CHRONIC  NASAL  CATARRR 

(Chronic  Rhinitis.) 

Definition. — A  chronic  inflammation  of  the  nasal 
mucous   membrane. 

etiology. — Repeated  attacks  of  acute  coryza,  impure 
air,  the  continual  inhalation  of  irritating  dusts  or  vapors, 
lowered  vitality,  and  congenital  or  acquired  obstruction  of 
the  nasal  chambers  are  causal  factors.  It  is  sometimes  an 
expression  of  syphilis. 

Varieties. — (i)  Simple  chronic  rhinitis  ;  (2)  hypertrophic 
rhinitis  ;  (3)  atrophic  rhinitis. 

Symptoms. — These  consist  in  a  mucoid  or  mucopuru- 
lent discharge  from  the  nose ;  obstruction  of  the  nostrils 
from  swelling  or  hypertrophy  of  the  mucosa  or  from  inspis- 
sated secretion  ;  mouth-breathing  ;  a  nasal  intonation  of  the 
voice;  frontal  headache;  and  impairment  of  the  sense  of  smell. 

Symptoms  of  catarrh  of  the  neighboring  organs  are  fre- 
quently present.  The  most  common  of  these  are :  dryness 
of  the  throat  and  hawking  from  pharyngitis;  deafness  from 
catarrh  of  the  middle  ear ;  and  watering  of  the  eyes  from 
catarrhal  occlusion  of  the  lacrimal  canal. 


CHRONIC  NASAL    CATARRH.  21/ 

Simple  Chronic  Rhinitis. — The  mucous  membrane  of  the 
nose  is  congested,  swollen,  and  highly  irritable.  There  is 
hypersecretion  of  mucus  or  mucopus. 

Hypertrophic  Rhinitis. — The  mucous  membrane  is  red  and 
the  cavities  are  more  or  less  occluded  from  hypertrophy  of 
the  cavernous  tissue  covering  the  turbinated  bones.  In 
advanced  cases  exostoses  from  the  bony  framework  are 
sometimes  noted.  The  secretion  is  usually  composed  of 
thick  mucopus.  Adenoid  growths  are  often  found  in  the 
nasopharynx. 

Atrophic  Rhinitis  (Ozena). — This  form  is  seen  most  fre- 
quently in  young  adults,  and  is  more  common  in  women 
than  in  men.  The  nasal  chambers  are  large ;  the  mucous 
membrane  is  pale,  dry,  and  glazed ;  adherent  scabs  are 
generally  present.  The  secretion  is  very  abundant,  thick, 
and  of  a  yellowish  or  greenish  color.  A  characteristic  feature 
is  the  extremely  offensive  odor,  which  is  probably  due  to  the 
decomposition  of  the  retained  secretion.  In  advanced  cases 
there  may  be  necrosis  of  the  bones  and  sinking  in  of  the 
bridge  of  the  nose. 

Prognosis. — In  the  simple  and  hypertrophic  form  the 
prognosis  is  favorable  under  persistent  treatment.  In  atro- 
phic rhinitis  perfect  cure  is  rarely  attainable,  but  great  im- 
provement is  possible. 

Treatment. — Any  constitutional  vice,  if  present,  should 
receive  appropriate  treatment.  Fresh  air,  outdoor  exercise, 
and  frequent  bathing,  with  friction  of  the  skin,  are  to  be 
recommended.  Tonics,  especially  str^^chnin  and  cod-liver 
oil,  are  often  required.  The  nasopharynx  must  be  kept 
clean  by  means  of  antiseptic  sprays,  such  as  Dobell's  solu- 
tion (see  p.  37)  or  the  following: 

R.     Sodii  bicarbonatis 

Sodii  boratis aa  gr.  xxx 

Sodii  chloridi g""-  iij 

Thymolis 

Mentholis aa  gr.  ss 

Olei  gaultheriae TTlij 

Glycerini f^ij 

Alcoholis f^ss 

Aquae q.  s,  ad  fjviij. — M. 


21 8         DISEASES   OF   THE   RESPIRATORY  SYSTEM. 

In  the  hypertrophic  form  local  remedies  of  an  astringent  or 
alterative  character  are  often  efficacious.  The  following  are 
in  common  use:  A  mixture  of  iodin  and  glycerin  contain- 
ing 6  grains  of  iodin,  I2  grains  of  potassium  iodid,  and  i 
ounce  each  of  glycerin  and  water ;  aqueous  solution  of 
ichthyol  (20  to  40  per  cer-t.) ;  solution  of  zinc  sulphocarbolate 
(2  to  5  per  cent.) ;  and  solution  of  silver  nitrate  (i  to  2  per 
cent). 

When  the  hypertrophic  process  proves  resistant,  the 
obstruction  must  be  removed  by  means  of  caustics  (chromic 
or  trichloracetic  acid),  the  galvanocautery,  or  the  snare. 

In  atrophic  rhinitis  the  crusts  may  be  removed  by  pled- 
gets of  cotton  soaked  in  a  solution  of  hydrogen  dioxid.  After 
the  nares  have  been  thoroughly  cleansed,  an  oily  solution 
like  the  following  may  be  applied : 

R .     Mentholis gr-  xx 

Thymolis g^'-  vj 

Eucalyptolis TTLxx 

Petrolati  liquid! f^vj.--M. 

For  destroying  the  offensive  odor  one  of  the  following 
applications  may  be  used :  Pledgets  of  cotton  soaked  in  an 
aqueous  solution  of  ichthyol  (20  to  50  per  cent.) ;  sprays  of 
formalin  (i  :  1000),  of  Labarraque's  solution  (i  :  30),  or  of 
potassium  permanganate  (2  grains  to  the  ounce). 

ACUTE  CATARRHAL  LARYNGITIS. 

Definition. — An  acute  catarrhal  inflammation  of  the 
larynx. 

;fetiolog"y. — Improper  use  of  the  voice,  exposure  to  cold 
and  wet,  and  the  inhalation  of  irritating  dusts  or  vapors  are 
its  common  causes.  It  may  be  excited  by  the  impaction  of 
a  foreign  body.  It  is  also  an  associated  condition  in  certain 
infectious  diseases,  Hke  whooping-cough,  measles,  diphtheria, 
and  influenza. 

Symptoms. — The  chief  symptoms  are  :  Hoarseness  of 
the  voice  or  aphonia ;  hard,  ringing  cough ;  pain  in  the 
throat,  increased  by  speaking,  coughing,  and  swallowing ; 
expectoration,  which  is  at  first  scanty  and  later  mucopurulent ; 


SPASMODIC  CROUP.  2I9 

fever  and  its  associated  symptoms.  In  sensitive  persons, 
and  especially  in  children,  paroxysms  of  croupy  cough  and 
dyspnea  {false  croup)  may  result  from  spasm  of  the  vocal 
cords.  When  there  is  much  edema,  severe  dyspnea  becomes 
a  prominent  feature. 

Inspection. — The  mucous  membrane  of  the  laryngeal 
walls  and  vocal  cords  is  red  and  swollen.  In  grave  cases 
the  tissues  are  highly  edematous. 

Prognosis. — In  simple  laryngitis  without  edema  the 
prognosis  is  altogether  favorable.  The  attack  usually  lasts 
from  a  week  to  ten  days.  When  there  is  edema  of  the 
larynx,  indicated  by  dyspnea  or  threatened  asphyxia,  the 
prognosis  is  grave. 

Treatment. — Use  of  the  voice  should  be  avoided.  The 
air  of  the  room  should  be  rendered  moist  by  means  of 
steam.  An  ice-bag  or  iodin  may  be  applied  externally.  At 
the  onset  it  is  advisable  to  administer  a  mild  aperient.  Mild 
expectorants — ipecac,  potassium  citrate,  or  ammonium 
chlorid — may  be  given  in  conjunction  with  heroin,  codein, 
or  paregoric  when  the  cough  is  troublesome.  Such  a  com- 
bination as  the  following  is  often  serviceable : 

R.     Potassii  citratis  ............    ^ij 

Vini  ipecacuanhae %i"^ 

Tincturae  opii  camphoratae ,  fi^iv 

Syrupi  tolutani fl^^s 

Aquae .  q.  s.  f^iv. — M. 

SiG. — A  dessertspoonful  every  three  hours. 

In  acute  edematous  laryngitis,  when  the  swelling  does  not 
yield  promptly  to  local  bloodletting,  the  external  apphcation 
of  ice,  astringent  sprays,  scarification  of  the  mucous  mem- 
brane, and  active  catharsis,  tracheotomy  should  be  performed 
without  delay. 

SPASMODIC  CROUP, 

(False  Croup ;  Catarrhal  Croup.) 

Definition. — Spasm  of  the  vocal  cords,  excited  by  catarrh 
of  the  larynx. 

etiology. — The  attacks  usually  occur  in  young  children, 
and  are  induced  by  the  causes  of  catarrhal  laryngitis. 


220        DISEASES   OF   THE   RESPIRATORY  SYSTEM. 

Symptoms. — Generally  there  has  been  a  little  hoarseness 
and  cough  during  the  day,  and  at  night  the  child  is  awak- 
ened from  sleep  by  a  severe  paroxysm  of  suffocative  cough. 
The  latter  has  a  peculiar,  hard,  metallic  quality,  and  is  asso- 
ciated with  the  evidences  of  dyspnea,  namely :  anxious  face, 
dilating  nostrils,  prominent  sternocleidomastoids,  and  retrac- 
tion of  the  base  of  the  chest  with  each  inspiratory  effort. 
During  the  paroxysm  the  skin  is  hot  and  the  pulse  is  tense 
and  rapid.  In  from  a  few  moments  to  an  hour  the  cough 
ceases,  free  perspiration  follows,  and  the  child  falls  asleep. 

Two  or  three  similar  attacks  may  occur  in  the  same  night, 
but  on  the  following  day  the  child  appears  quite  well.  A 
recurrence  of  the  seizures  for  several  successive  nights  is  not 
infrequent. 

Diagnosis. — Membranous  or  Pseudomembranous  Croup 
(Diphtheria). — Hoarseness  and  dyspnea  develop  gradually, 
and  the  latter  is  not  intermittent.  False  membrane  may  be 
seen  in  the  throat  or  may  be  coughed  up.  The  constitu- 
tional symptoms  are  more  severe. 

Laryngismus  Stridulus. — This  is  a  pure  neurosis,  and  is 
often  associated  with  the  rachitic  diathesis.  The  paroxysms 
resemble  those  of  false  croup,  but  are  associated  with  a  pecu- 
liar crowing  inspiration,  and  lack  catarrhal  symptoms,  such 
as  hoarseness  and  cough. 

Prognosis.  — Always  favorable. 

Treatment. — A  sponge  moistened  with  hot  water  may 
be  applied  to  the  throat,  or  the  child  may  be  placed  in  a  hot 
bath.  If  these  simple  measures  fail,  an  emetic  will  almost 
invariably  bring  relief  Wine  of  ipecac  (i  dram)  may  be 
selected.  Subsequent  treatment  should  be  directed  to  the 
laryngeal  catarrh.  A  mixture  like  the  following  will  be 
found  useful : 

R,    Tincturae  aconiti TTLxx 

Vini  ipecacuanhae f^lj 

Potassii  bromidi ^ss 

Potassii  citratis .    .    .    J^j 

Syrupi  tolutani      f 5j 

Aquse q.  s.  ad  f  Jij. — M. 

SiG. — A  teaspoonful  every  two  or  three  hours  for  a  child  of  two 
years. 


CHRONIC  LARYNGITIS.  221 

MEMBRANOUS  CROUR 

(Croupous  Laryngitis ;  True  Croup  ;  Pseudomembranous 

Laryngitis.) 

See  Laryngeal  Diphtheria. 


CHRONIC  LARYNGITIS* 

Simple  Chronic  Catarrhal  I/aryngitis. — This  may 
follow  an  acute  attack,  or  it  may  develop  gradually  from 
overuse  of  the  voice,  excessive  smoking,  or  inhalation  of 
dust  or  irritant  vapors. 

Symptoms. — These  consist  in  moderate  hoarseness,  apho- 
nia after  continued  speaking,  slight  cough,  and  scanty  ex- 
pectoration of  grayish  mucus  tinged  with  dust  or  other 
impurities. 

Laryngoscopic  examination  reveals  redness  and  swelling 
of  the  vocal  cords  or  of  the  entire  larynx. 

Treatment. — The  use  of  the  voice  should  be  restricted. 
Coexisting  nasal  or  pharyngeal  disease  should  receive  atten- 
tion. The  patient  must  learn  to  use  the  voice  properly, 
expelling  sounds  by  the  abdominal  muscles  and  diaphragm, 
and  not  by  the  muscles  of  the  throat.  Flannel  protectors 
should  be  avoided,  and  the  application  of  cool  water  to  the 
neck,  night  and  morning,  instituted  in  their  stead.  Tonics 
are  frequently  indicated. 

Thorough  cleansing  of  the  nose,  throat,  and  larynx  should 
be  secured  by  means  of  mild  alkaline  sprays  (Dobell's  solu- 
tion). Astringent  sprays  like  the  following  are  useful : 
Zinc  acetate,  3  to  5  grains  to  the  ounce ;  zinc  sulphocarbo- 
late,  2  to  3  grains  to  the  ounce ;  alum,  3  to  5  grains  to  the 
ounce.  Direct  applications  of  silver  nitrate  (3  to  5  grains 
to  the  ounce)  are  also  very  efficacious. 

Tuberculous  I<aryngitis. — This  may  be  primary ,  but 
it  is  more  often  secondary  to  tuberculosis  elsewhere,  espe- 
cially the  lung. 

Symptoms. — These  consist  in  hoarseness,  aphonia,  hacking 
cough,  and  pain  in  the  throat,  increased  by  coughing,  speak- 
ing, and  swallowing. 


222         DISEASES   OF   THE   RESPIRATORY  SYSTEM. 

Laryngoscopic  Examination. — The  mucous  membrane  is 
swollen,  pale,  and  edematous.  The  arytenoid  cartilages  are 
especially  involved,  and  the  membrane  between  them  is 
often  the  seat  of  a  hill-like  infiltration.  Tuberculous  ulcers 
are  usually  shallow  and  have  a  broad  base,  an  irregular  out- 
Hne,  and  an  uneven  surface.     They  are  extremely  painful. 

Treatment. — The  general  treatment  should  be  that  of  pul- 
monary tuberculosis.  The  parts  should  be  freq.uently 
cleansed  with  alkaline  detergent  sprays.  Terebene,  com- 
pound tincture  of  benzoin,  or  eucalyptol  may  be  used  in  a 
respirator  or  inhaled  from  the  surface  of  boiling  water. 
Radical  treatment  consists  in  rubbing  in,  under  cocain  anes- 
thesia, lactic  acid  (30  to  75  per  cent,  solutions).  Palliative 
treatment  consists  in  applying  cocain  in  solution  (4  to  10 
per  cent.)  or  orthoform,  morphin,  or  iodoform  in  powder. 
The  following  insufflation  is  useful : 

R  ■     Orthoform     . .  gr.  j 

Acidi  borici      ......        .    .    .    .  gr.  j 

Morphinae  sulphatis     ........  gr.  i. 

Syphilitic  laryngitis  may  manifest  itself  as  a  catarrhal 
inflammation,  mucous  patches,  gummatous  infiltration,  or 
ulceration.  The  ulcers  are  more  or  less  circular,  deep,  and 
sharply  circumscribed.  They  are  frequently  found  on  the 
epiglottis.  Rapid  necrosis  and  exfoliation  of  the  cartilage 
may  follow.     Pain  is  often  slight. 

Diagnosis. — The  history,  the  presence  of  other  syphilitic 
lesions,  the  deep,  clean-cut,  rapidly  spreading  ulcers,  the  effect 
of  treatment,  and  the  absence  of  marked  pain  and  of  pulmo- 
nary lesions  well  serve  to  distinguish  syphilis  from  tuber- 
culosis. 

Treatment. — Constitutional  treatment  with  iodids  and 
mercurials  is  of  the  first  importance.  Local  cleanliness 
should  be  secured  by  thorough  spraying  with  some  alkaline 
antiseptic  solution.  Ulcers  may  be  touched  with  silver 
nitrate  (melted  on  a  silver  probe),  acid  nitrate  of  mercury  (i 
to  5  parts  of  water),  or  chromic  acid  (i  to  8  parts  of  water). 
Insufflations  of  iodoform  are  also  useful.  Cicatricial  steno- 
sis may  call  for  gradual  dilatation  or  even  tracheotomy. 


LARYNGISMUS  STRIDULUS.  223 

LARYNGISMUS  STRIDULUS, 

(Spasm  of  the  Glottis ;  Laryngospasmus  ;  "  Child-crowing.") 

Definition. — A  paroxysmal  neurosis,  characterized  by 
reflex  spasm  of  the  adductors  of  the  larynx,  and  not  excited 
by  any  local  inflammation. 

etiology. — It  usually  occurs  in  rachitic  infants  between 
six  months  and  two  years  of  age.  The  attacks  may  be 
brought  on  by  fright,  gastric  irritation,  exposure,  or  a  sud- 
den movement. 

Symptoms. — The  attacks  often  occur  on  waking  from 
sleep,  and  are  characterized  by  a  sudden  arrest  of  breathing 
and  tonic  muscular  spasms.  The  face  is  pale,  and  later 
cyanosed ;  the  eyes  are  rolled  up ;  the  body  is  arched  ;  the 
thumbs  are  turned  into  the  palms ;  the  legs  are  extended, 
and  the  soles  turned  inward.  In  a  few  seconds  the  spasm 
relaxes,  and  air  is  drawn  through  the  glottis  with  a  shrill, 
crowing  sound. 

The  seizures  vary  greatly  in  frequency :  several  may 
occur  in  a  day,  or  they  may  be  weeks  apart 

Diagnosis. — The  intermittent  character  of  the  affection  ; 
the  pecuhar  crowing  inspiration  ;  the  absence  of  fever,  cough, 
and  hoarseness  will  serve  to  distinguish  laryngismus  from 
croup. 

Prognosis. — Favorable.  In  the  very  young  death  may 
result  from  suffocation. 

Treatment.  —  The  Paroxysm. — Cold  water  may  be 
dashed  on  the  face  and  head,  or  a  few  drops  of  nitrite  of 
amyl  may  be  placed  on  a  handkerchief  and  held  before  the 
nose. 

The  Interval. — Careful  search  should  be  made  for  some 
exciting  cause ;  the  gums  may  require  lancing,  or  the  gas- 
tro-intestinal  tract  may  demand  attention.  The  child  should 
be  placed  under  the  best  hygienic  conditions.  The  food 
should  be  plain  and  nutritious ;  tonics,  like  cod-liver  oil, 
hypophosphites,  and  arsenic,  are  generally  indicated.  The 
bromid  of  sodium  is  an  efficient  antispasmodic,  and  may  be 
advantageously  combined  with  antipyrin  : 


224        DISEASES   OF  THE  RESPIRATORY  SYSTEM, 

R.     Sodii  bromidi ,^iss 

Antipyrinae gr.  xx-xxx 

Glycerini       f^ss 

Aquae  menthae  piperitae fjiij- 

SiG. — A  teaspoonful  four  times  a  day. 

EDEMA  OF  THE  LARYNX. 

(Edema  of  the  Glottis.) 

Definition. — An  infiltration  of  serous  fluid  into  the  sub- 
mucous tissue  of  the  larynx. 

!^tiology. — It  occasionally  results  from  severe  attacks 
of  catarrhal  laryngitis.  It  may  be  induced  by  severe  in- 
flammation of  neighboring  organs — as  the  tonsils,  parotid 
glands,  and  pharynx.  It  may  be  a  compHcation  of  some 
acute  infectious  disease — like  diphtheria,  scarlet  fever,  or 
facial  erysipelas.  It  is  sometimes  associated  with  ulcerative 
affections  of  the  larynx,  like  tuberculosis  and  syphiHs.  It 
may  be  excited  by  the  irritation  of  burns,  scalds,  or  caustics. 
It  occasionally  occurs  abruptly  in  the  course  of  Bright's 
disease. 

Pathology. — The  connective  tissue  of  the  larynx  is  in- 
filtrated with  a  serous  or  seropurulent  fluid.  The  mucous 
membrane  is  tense  and  changed  in  color. 

Symptoms. — These  are :  hoarseness  of  the  voice,  and 
later  aphonia;  extreme  dyspnea,  at  first  on  inspiration,  but 
later  on  expiration  also ;  stridulous  respiration ;  barking 
cough  ;  and  the  evidences  of  dyspnea — namely,  anxious 
face,  protruding  eyes,  blue  lips,  prominent  sternocleido- 
mastoids, and  retraction  of  the  base  of  the  chest.  When 
the  epiglottis  is  involved,  the  swelling  can  be  detected  by 
the  finger  in  the  throat. 

Laryngoscopic  Examination. — The  mucous  membrane  is 
swollen  and  of  a  reddish-purple  color.  The  epiglottis  may 
resemble  a  round,  translucent  tumor.  In  infraglottic  edema 
the  upper  part  of  the  larynx  may  appear  normal,  but  swollen 
and  edematous  membrane  is  seen  projecting  through  the 
glottis.     The  vocal  cords  are  rarely  affected. 

Prognosis. — Extremely  grave. 

Treatment. — Mild  inflammatory  edema  sometimes  yields 


BR  ONCHITIS.  12<^ 

to  the  sucking  of  ice,  local  bloodletting,  the  application  of 
ice  to  the  neck,  astringent  sprays  (alum,  adrenalin,  tannic 
acid),  and  the  administration  of  saline  purges.  When  the 
symptoms  become  urgent,  the  parts  should  be  scarified 
under  cocain  anesthesia,  and  if  this  fails,  tracheotomy  should 
be  performed  at  once. 


DISEASES  OF  THE  LUNGS. 
BRONCHITIS. 

Definition. — An  inflammation  of  the  bronchial  tubes, 
characterized  by  substernal  soreness,  cough,  mucopurulent 
expectoration,  and  dry  and  moist  rales. 

Varieties.— (i)  Acute  catarrhal  bronchitis  ;  (2)  chronic 
catarrhal  bronchitis ;  (3)  fibrinous  bronchitis. 

ACUTE  CATARRHAL  BRONCHITIS. 

etiology. — A  cold,  damp  climate ;  changeable  weather  ; 
occupations  that  necessitate  confinement  or  the  inhalation 
of  irritating  dusts  or  vapors ;  the  gouty  diathesis ;  and 
chronic  heart  disease  are  general  predisposing  factors. 

Exposure  to  cold  and  wet,  particularly  when  the  body  is 
overheated,  or  the  inhalation  of  irritating  gases  or  dusts  is 
the  usual  exciting  cause.  Acute  bronchitis  is  also  an  asso- 
ciated condition  in  certain  infectious  diseases,  especially 
measles,  whooping-cough,  typhoid  fever,  and  influenza. 

Micro-organisms  (streptococcus,  staphylococcus,  and  pneu- 
mococcus)  are  without  doubt  important  etiologic  factors. 

Pathology. — In  most  cases  the  trachea  and  large  tubes 
only  are  affected.  The  mucous  m^embrane  is  red,  swollen, 
injected,  and  more  or  less  covered  with  tenacious  mucopus. 

Microscopic  examination  reveals  desquamation  of  epithe- 
lium and  infiltration  of  the  submucous  tissues  with  leuko- 
cytes. 

Symptoms. — The  chief  features  are:  Chilliness;  malaise; 
a  sense  of  soreness  and  constriction  behind  the  sternum, 
which  is  increased  by  coughing;  slight  fever  (100°  to  102° 
F.),  with  its  associated  symptoms ;  and  cough,  which  is  at 

15 


226        DISEASES   OF  THE  RESPIRATORY  SYSTEM. 

first  dry  and  painful,  but  later  accompanied  by  free  muco- 
purulent expectoration. 

Physical  Signs. — Inspection,  palpation,  and  percussion 
usually  give  negative  results. 

Auscultation  at  first  reveals  sibilant  and  sonorous  rales 
on  both  sides  of  the  chest,  and  in  the  second  stage,  when 
secretion  is  established,  moist  rales. 

Diagnosis. — Influenza. — High  fever,  severe  pain  in  the 
head,  back,  and  limbs,  and  great  prostration  will  serve  to 
distinguish  influenza  from  bronchitis  when  the  former  is 
prevalent. 

Catarrhal  Pneumonia. — Moderately  high  and  irregular 
fever,  prostration,  pronounced  dyspnea,  cyanosis,  and  phy- 
sical signs  indicating  consolidation  will  aid  in  the  recognition 
of  pneumonia. 

Prognosis. — Favorable.  In  the  old,  young,  and  feeble 
there  is  danger  of  its  leading  to  capillary  bronchitis  or  ca- 
tarrhal pneumonia.    The  duration  is  from  one  to  three  weeks. 

Treatment. — If  the  patient  be  weak  or  old,  he  should 
be  confined  to  his  room  or  even  to  bed ;  the  atmosphere 
of  the  room  should  be  kept  warm  and  moist.  If  the  patient 
be  seen  at  the  outset,  it  is  useful  to  promote  free  diapho- 
resis, and  this  may  be  accomplished  by  means  of  a  hot 
foot-bath,  with  hot  drinks  and  a  full  dose  of  Dover's  pow- 
der. Counterirritation  to  the  chest  in  the  form  of  sinapisms 
or  stupes  is  very  beneficial.  The  food  should  be  simple 
and  readily  digestible,  and  the  bowels  should  be  kept  reg- 
ularly open  by  the  aid  of  mild  aperients.  In  the  early 
stage,  when  there  is  no  secretion,  sedative  expectorants — 
ipecac,  potassium  citrate,  tartar  emetic,  and  apomorphin — 
are  indicated.  It  is  usually  necessary  to  add  a  sedative, 
like  opium  or  one  of  its  derivatives  (codein,  ■§-  to  -|-  grain,  or 
heroin,  y^g  to  -^  grain)  to  allay  the  distressing  cough.  A 
combination   like  the  following  will  be  found  useful : 

R.    Potassii  citratis ^iij 

Vini  ipecacuanhae f^iiss 

Tincturse  opii  camphoratae fziij 

Succi  limonis ffj 

Syrupi q.  s,  fgvj, — M. 

SiG. — A  tablespoonful  every  four  hours. 


BRONCHITIS.  227 

When  the  secretion  becomes  more  abundant,  stimulant 
expectorants  are  indicated.  One  of  the  most  reliable  mem- 
bers of  this  class  is  ammonium  chlorid ;  it  may  be  pre- 
scribed in  some  simple  vehicle,  like  brown  mixture,  or  with 
squills,  as  in  the  following  formula : 

5t.    Ammonii  chloridi ^iiss 

Syrupi  scillae f^v 

Tincturae  opii  deodorati TTL^^ 

Extract!  glycyrrhizae '^] 

Glycerini f^ss 

Aquae q.  s,  ad  f^iv. — M. 

SiG. — A  dessertspoonful  in  water  every  four  hours. 

Among  other  useful  stimulant  expectorants  may  be  men- 
tioned terpin  hydrate,  terebene,  oil  of  eucalyptus,  oil  of 
santal,  and  tar.  Such  combinations  as  the  following  are 
often  serviceable  when  the  catarrh  tends  to  become  subacute: 


R.    Terebini 

Olei  santali aa  f^ss 

Strychninae  sulphatis g^-  :? 

Codein.  sulphatis gr.  ij-iij. — M. 

Pone  in  capsulas  No.  xij. 

SiG. — One  every  four  hours. 


Or 


R.    Ammonii  chloridi .    .    .    ^j 

Vini  picis  liquidae 

Misturae  glycyrrhizae  compositae     .      aa  f^iss. — M. 
SiG. — A  dessertspoonful  every  two  or  three  hours.     (MussER.) 

In  the  aged  and  infirm  alcoholic  stimulants  are  often  re- 
quired to  combat  general  adynamia.  Strychnin  is  a  most 
valuable  adjunct  to  the  expectorants  when  there  are  indica- 
tions that  the  heart  is  becoming  strained  by  the  violent 
paroxysms  of  cough.  Should  there  be  evidence  of  pro- 
nounced cardiac  failure,  it  will  be  necessary  to  employ 
digitalis. 

Such  tonics  as  cod-liver  oil,  iodid  of  iron,  quinin,  and 
arsenic  are  often  useful  during  convalescence  from  severe 
and  prolonged  attacks.  Much  benefit  will  also  be  obtained 
from  suitable  change  of  climate. 


228         DISEASES   OF   THE   RESPIRATORY  SYSTEM. 

CHRONIC  BRONCHITIS, 
(Chronic  Bronchial  Catarrh ;  Winter  Cough.) 

i^tiology. — It  may  result  from  the  continuation  of  an 
acute  attack ;  but  more  frequently  it  develops  gradually  in 
association  with  gout  or  chronic  heart  or  kidney  disease. 
It  is  especially  common  in  the  old.  It  is  an  associated  con- 
dition in  emphysema,  phthisis,  chronic  interstitial  pneumonia, 
and  in  many  cases  of  asthma. 

Pathology. — The  mucous  membrane  of  the  bronchi  is 
sometimes  thickened  and  roughened  from  an  overgrowth 
of  the  connective  tissue ;  in  other  cases  the  mucosa  is  thin 
from  atrophic  changes.  The  surface  is  usually  covered  with 
mucopus ;  ulcers  are  occasionally  noted. 

Long-standing  bronchitis  leads  to  dilatation  of  the  tubes 
(bronchiectasis)  and  to  emphysema. 

Symptoms. — The  chief  features  are  :  Persistent  cough 
with  more  or  less  mucopurulent  expectoration ;  a  sense  of 
soreness  behind  the  sternum.  Fever  is  usually  absent,  and 
unless  the  disease  is  very  severe,  the  general  health  may  be 
fairly  well  preserved.  Dyspnea  on  exertion  is  sometimes 
a  troublesome  symptom  ;  it,  however,  belongs  more  to  the 
resulting  emphysema  than  to  the  bronchitis. 

Physical  Signs. — Unless  emphysema  has  developed, 
inspection,  palpation,  and  percussion    give  negative  results. 

Auscultation  sometimes  reveals  rales,  some  of  which  are 
dry  and  wheezing,  while   others  are  moist  and  bubbling. 

Bronchorrhea. — This  term  is  applied  to  cases  of  chronic 
bronchitis  which  are  associated  with  a  very  copious  expec- 
toration. The  sputum  is  generally  mucopurulent,  and 
sometimes  very    offensive  (fetid  bronchitis.) 

Dry  Catarrh. — This  form,  described  by  Laennec  as  ca- 
tarrhe  sec,  is  characterized  by  severe  spells  of  coughing  that 
are  accompanied  by  little  or  no  expectoration.  It  is  gen- 
erally seen  in  the  old  in  association  with  emphysema  or 
asthma. 

Diagnosis. — Phthisis. — The  absence  of  fever,  of  hemor- 
rhage, of  bacilli  in  the  sputa,  and   of  signs   indicating  con- 


BR  ORCHITIS.  2  29 

solidation  will  serve  to  distinguish  chronic  bronchitis  from 
phthisis. 

Bronchiectasis. — This  often  results  from  chronic  bron- 
chitis. It  is  characterized  by  paroxysms  of  cough  attended 
with  the  expectoration  of  large  quantities  of  purulent  secre- 
tion of  an  extremely  offensive  odor.  There  may  be,  also, 
physical  signs  of  one  or  more  cavities  near  the  root  or  base 
of  the  lung. 

Emphysema. — Marked  dyspnea,  distention  of  the  chest, 
hyperresonance  on  percussion,  and  a  prolonged  feeble  ex- 
piration on  auscultation  will  indicate  emphysema. 

Seqtielse. — Emphysema,  bronchiectasis,  and  dilatation  of 
the  right  ventricle. 

Prognosis. — Perfect  recovery  is  rarely  attainable,  but  the 
disease  is  not  incompatible  with  long  life. 

Treatment. — Treatment  must  be  directed  toward  the 
prevention  of  recurrent  attacks,  and  the  removal,  if  possible, 
of  the  underlying  cause.  Change  of  climate,  especially  in 
winter,  is  most  beneficial.  When  there  is  much  secretion,  a 
dry,  warm  climate  is  generally  to  be  recommended,  whereas 
if  there  be  little  expectoration,  a  moist  warm  climate  is 
preferable.  When  patients  cannot  afford  to  travel,  they 
should  remain  indoors  as  much  as  possible  in  bad  weather, 
and  take  every  precaution  against  exposure.  Flannel  should 
at  all  times  be  worn  next  to  the  skin,  the  feet  should  be  kept 
dry,  and  night  air  should  be  avoided. 

Underlying  chronic  diseases  should  receive  appropriate 
treatment.  When  cardiac  insufficiency  is  present,  digitalis 
or  strychnin  will  be  required.  When  there  is  general 
malnutrition,  such  remedies  as  iron,  arsenic,  cod-liver  oil,  and 
hypophosphites  may  be  given  with  advantage.  When  gout 
is  a  factor,  iodids  and  alkalis  will  prove  serviceable. 

The  most  useful  direct  remedies  are  the  stimulant  ex- 
pectorants, such  as  terebene,  oil  of  eucalyptus,  myrtol,  oil  of 
santal,  oil  of  copaiba,  oil  of  cubeb,  and  tar.  When  the 
sputum  is  heavy  and  purulent,  no  drug  acts  so  well  as  crea- 
sote  or  the  carbonate  of  guaiacol.  Potassium  iodid  may  be 
tried  when  the   expectoration   is   scanty  and  viscid.     Mild 


230        DISEASES   OF   THE   RESPIRATORY  SYSTEM. 

anodynes — heroin  or  codein — are  often  necessary  to  control 
harassing  cough.  The  following  formulas  will  illustrate  the 
manner  in  which  these  remedies  may  be  combined : 

R.    Terebini 

Olei  eucalypti 

Olei  santali aa    f^j-iss 

Codeinae gr.  iij-vj. — M. 

Pone  in  capsulas  No.  xxiv. 

SiG. — One  after  each  meal  and  at  bedtime. 


R.    Terpini  hydratis ^j 

Guaiacolis  carbonatis ^ij 

Strychninae  sulphatis gr.  ss 

Codeinse gr.  iij. — M. 

Pone  in  capsulas  No.  xxiv. 

SiG. — One  or  two  capsules  three  or  four  times  a  day. 

R.    Apomorphinse  hydrochloridi gr.  5s 

Syrupi  pruni  virginianse f^ij 

Syrupi  picis  liquidse C,l^^- — •'^• 

SiG. — A  tablespoonful  thrice  daily.     (Murrell.) 

Inhalations  (eucalyptol,  terebene,  oil  of  Scotch  fir,  com- 
pound tincture  of  benzoin,  etc.)  are  often  efficacious.  Such 
a  mixture  as  the  following  may  be  employed  several  times  a 
day  in  an  oronasal  respirator : 

R .    Chloroform! f^ss 

Creasoti 

Terebini 

Olei  pini  sylvestris aa  f;^iss 

Alcoholis q.  s.  ad  f^^j. 

SiG. — From  5  to  20  drops  to  be  used  in  the  inhaler  several  times 
a  day. 

CountermHtatio?i ,  preferably  with  iodin  or  small  blisters,  is 
often  of  great  service  in  lessening  the  severity  of  acute 
exacerbations. 


BRONCHITIS.  231 

FIBRINOUS  BRONCHITIS. 
(Croupous  Bronchitis ;  Pseudomembranous  Bronchitis.) 

Definition. — A  rare  affection  characterized  by  the  ex- 
pectoration of  fibrinous  casts  of  certain  portions  of  the  bron- 
chial tree. 

!]^tiolog"y. — The  causes  are  unknown.  In  some  cases  it 
has  been  associated  with  tuberculosis,  while  in  others  there 
has  been  chronic  heart  disease. 

Patholog'y. — The  disease  is  often  limited  to  a  certain 
number  of  bronchi.  Some  of  the  affected  tubes  are  found 
filled  with  a  fibrinous  exudate,  while  others  are  found  empty 
and  show  a  loss  of  epithelium.  The  casts  are  usually  ex- 
pelled in  the  form  of  whitish  balls,  which,  when  unrolled  in 
water,  present  branching  molds  of  the  divisions  and  sub- 
divisions of  the  affected  bronchi.  On  close  examination  they 
are  found  to  be  hollow  and  laminated.  Under  the  micro- 
scope, a  homogeneous  or  fibrillated  membrane  is  observed, 
imbedded  in  which  are  leukocytes,  fat-drops,  particles  of 
pigment,  epithelial  cells,  and  occasionally  Leyden's  octa- 
hedral crystals. 

Symptoms. — Acute  and  chronic  forms  are  recognized. 
The  former  is  rare,  and  manifests  the  symptoms  of  a  severe 
attack  of  acute  bronchitis,  but  the  sputa  contain  fibrinous 
casts  and  there  is  marked  dyspnea. 

The  chronic  form  is  characterized  by  severe  cough,  parox- 
ysms of  dyspnea,  and  the  expectoration  of  fibrinous  plugs. 
Hemoptysis  is  not  uncommon.  The  physical  signs  are 
those  of  chronic  bronchitis  and  emphysema.  The  disease 
often  lasts  a  few  weeks,  and  then  disappears,  to  return  again 
at  definite  periods. 

Prognosis. — In  the  acute  variety  the  prognosis  must  be 
guarded ;  death  frequently  results  from  suffocation. 

The  chronic  variety  runs  a  very  protracted  course. 

Treatment. — In  the  acute  cases  the  atmosphere  of  the 
room  should  be  kept  moist  and  uniformly  warm.  Inhala- 
tions of  alkaline  vapors  (lime-water)  appear  to  be  beneficial. 
Counterirritants  should  be  applied  to  the  chest.  Emetics 
sometimes  aid  in  the  expulsion  of  loose  casts.  Sedative  or 
stimulant  expectorants   may  be  prescribed,  as  in   catarrhal 


232         DISEASES   OF   THE   RESPIRATORY  SYSTEM. 

bronchitis.     In  the  chronic  form  potassium  iodid  may  also 
be  given. 

BRONCHIECTASIS. 

(Dilatation  of  the  Bronchi.) 

Definition. — A  uniform  or  circumscribed  dilatation  of 
the  bronchi. 

Btiology. — It  is  most  frequently  the  result  of  chronic 
bronchitis,  weakening  of  the  walls  of  the  bronchi  from  the 
inflammation  and  increased  pressure  from  the  violent  cough- 
ing being  the  determining  factors.  It  is  occasionally  excited 
by  obstruction  to  a  bronchus  from  a  foreign  body  or  the 
pressure  of  an  aneurysm.  Finally,  the  contraction  of  over- 
grown connective  tissue  in  fibroid  pneumonia,  chronic 
phthisis,  and  chronic  pleural  thickening  sometimes  induces 
marked  ectasy. 

Pathology. — Two  forms  are  noted:  (i)  The  cylindric 
form,  in  which  the  tubes,  particularly  those  of  medium  size, 
are  uniformly  dilated  in  one.  or  both  lungs  ;  and  (2)  the 
saccular  form,  in  which  the  tubes  swell  out,  here  and  there, 
into  circumscribed  dilatations  that  may  reach  several  inches 
in  diameter.  Bronchiectatic  cavities  are  lined  with  mucous 
membrane,  but  the  latter  is  often  atrophied,  indurated,  or 
ulcerated. 

Symptoms. — The  chief  symptoms  are  paroxysmal  cough, 
dyspnea,  and  copious  expectoration.  The  last  is  character- 
istic ;  it  is  apt  to  occur  periodically  in  gushes ;  the  material 
has  a  highly  offensive  odor,  and  when  allowed  to  stand  in  a 
glass  vessel,  separates  into  three  layers  :  an  upper  layer  of 
dirty  brown  froth,  a  middle  layer  of  turbid  mucus,  and  an 
under  layer  of  decomposed  pus.  Microscopically,  it  contains 
pus-corpuscles,  fat  crystals,  crystals  of  hematoidin,  and 
numerous  micro-organisms,  but  no  tubercle  baciUi.  Elastic 
fibers  are  rarely  found.     Hemoptysis  is  not  uncommon. 

Physical  Signs. — In  the  cylindric  variety  the  signs  are 
those  of  chronic  bronchitis.  The  saccular  variety  may  pre- 
sent the  signs  of  tuberculous  cavities — locahzed  tympany, 
cavernous  breathing,  gurgling  rales,  and  pectoriloquy.    Bron- 


ASTHMA.  233 

chiectatic  cavities  are  usually  near  the  root  or  the  base  of  the 
lung. 

Diagnosis. — Phthisis. — The  marked  constitutional  symp- 
toms, the  apical  location  of  the  cavities,  the  signs  of  consoli- 
dation around  the  cavities,  and  the  presence  of  tubercle  bacilli 
in  the  sputum  will  estabhsh  the  diagnosis. 

Prog"nosiS. — There  is  little  prospect  of  cure,  but  life  may 
be  prolonged  indefinitely. 

Treatment. — The  general  treatment  is  that  of  chronic 
bronchitis.  The  most  useful  expectorants  are  oil  of  eucalyp- 
tus, oil  of  santal,  terebene,  tar,  guaiacol  carbonate,  and  crea- 
sote.  Inhalations  of  terebene,  carbolic  acid,  creasote,  etc., 
lessen  cough  and  aid  in  destroying  the  fetid  odor  of  the 
breath.  When  a  single  large  cavity  can  be  definitely  located 
in  the  lower  lobe,  incision  and  drainage  may  be  considered. 

ASTHMA. 

Definition. — Paroxysmal  dyspnea  due  to  spasm  of  the 
bronchi  or  to  sudden  sweUing  of  the  bronchial  mucosa. 

!^tiology. — Asthma  is  a  symptom  of  several  diseases, 
but  a  hypersensitive  condition  of  the  mucous  membrane  of 
the  respiratory  tract  appears  to  be  essential  to  its  production. 
When  this  condition  prevails,  asthma  may  be  induced — (i) 
By  the  pulmonary  congestion  of  cardiac  disease  (cardiac 
asthma);  (2)  by  the  uremic  intoxication  or  transient  pul- 
monary edema  of  Bright's  disease  (renal  asthma);  or  (3)  by 
some  irritant  from  without,  as  the  pollen  of  plants  (hay- 
asthma)  ;  (4)  sometimes  the  paroxysms  are  excited  by  the 
most  trivial  causes,  as  an  atmospheric  change  or  a  pecuHar 
odor,  and  to  this  form  many  writers  restrict  the  term  asthma. 
This  last  will  be  discussed  under  the  head  of  Essential  Asthma. 

ESSENTIAL  ASTHMA. 
(Bronchial  Asthma;  Nervous  Asthma;   Spasmodic  Asthma.) 

!^tiology. — Heredity,  a  neurotic  temperament,  and  lesions 
of  the  upper  air-passages  (hypertrophic  rhinitis,  polyps,  etc.) 
are  predisposing  factors.  More  males  are  affected  than 
females.    It  may  develop  at  any  age.    Atmospheric  changes, 


234        DISEASES   OE  THE   RESPIRATORY  SYSTEM. 

the  inhalation  of  certain  kinds  of  dust,  the  odor  of  certain 
animals  or  plants,  reflex  irritation,  indigestion,  a  change  of 
locality,  or  bronchial  catarrh  may  serve  as  an  exciting  cause. 

Pathology. — The  disease  is  a  pure  neurosis,  and  the 
paroxysms  probably  result  from  spasm  of  the  bronchial 
muscles  or  a  sudden  vasomotor  turgescence  of  the  bronchial 
mucosa. 

Symptoms. — The  paroxysms  often  appear  suddenly,  but 
in  some  cases  certain  symptoms  precede  and  give  warning 
of  the  approaching  attack ;  among  these  are  chilliness, 
flatulence,  sneezing,  and  a  copious  discharge  of  pale  urine. 
The  attacks  most  often  occur  at  night.  There  is  a  sense  of 
oppression  and  anxiety,  followed  by  dyspnea  so  intense  that 
the  patient  runs  to  the  window  for  air,  or  sits  upright  with 
his  arms  in  such  a  position  that  he  can  bring  into  play  the 
auxiliary  muscles  of  respiration.  The  face  is  pale  and 
anxious,  the  Hps  are  blue,  and  the  surface  is  covered  with 
profuse  perspiration.  The  respirations  are  not  rapid,  but 
labored  and  noisy.  Cough  is  usually  present,  and  is  asso- 
ciated with  the  expectoration  of  thick,  tenacious  mucus. 
On  close  examination  little  grayish  plugs  can  be  detected  in 
the  sputum.  These,  under  a  pocket-lens,  are  seen  to  consist 
of  delicate  spirals  of  mucus  that  have  been  molded  in  the 
finer  bronchioles  (Curschmann's  spirals). 

Microscopic  examination  also  reveals  eosinophile  cells  and 
octahedral  crystals  (Charcot-Leyden  crystals). 

The  paroxysms  may  last  from  a  few  minutes  to  many 
hours,  and  may  recur  for  several  successive  nights,  or  may 
disappear  entirely  for  weeks  or  months. 

Physical  Signs. — Inspection  reveals  expiratory  dyspnea 
and  distention  of  the  chest.     ^ 

Percussion  reveals  hyperresonance. 

Auscultation. — Vesicular  breathing  is  weak  and  obscured 
by  abundant  sibilant  and  sonorous  rales.  The  latter  are  espe- 
cially marked  in  expiration,  which  is  greatly  prolonged  and 
wheezy. 

Diagnosis. — Cardiac  and  renal  asthma  are  to  be  distin- 
guished from  essential  asthma  by  the  history  and  by  the 
evidence  of  organic  heart  or  kidney  disease. 


ASTHMA.  235 

Hay-asthma  may  be  recognized  by  the  periodicity  of  the 
attacks  and  the  associated  coryza  and  sneezing. 

Laryngeal  Obstruction  from  Foreign  Bodies,  Croup,  Paralysis 
of  the  Vocal  Cords,  or  Edema. — The  dyspnea  is  with  inspira- 
tion, and  the  chest,  instead  of  being  distended,  is  retracted, 
especially  at  the  base. 

Sequelae. — Emphysema  invariably  follows  when  the 
asthma  is  of  long  duration  ;  it  results  from  the  tension  to 
which  the  vesicles  are  subjected  during  the  expiratory  effort. 
Dilatation  of  the  right  ventricle  is  also  a  remote  sequel. 

Prognosis. — The  disease  does  not  prove  fatal  except 
through  complications  or  sequelae.  Recovery  is  rare.  Cases 
associated  with  some  definite  reflex  irritation,  as  nasal  ob- 
struction, occasionally  recover  when  the  cause  is  removed. 

Treatment. — The  Interval. — The  cause  must  be  sought 
for  in  every  case,  and  removed  if  possible.  Digestive  dis- 
turbances should  always  receive  careful  attention.  Chronic 
bronchitis,  emphysema,  and  dilatation  of  the  heart  are  fre- 
quent concomitants  of  asthma  and  call  for  special  treatment. 
Change  of  cHmate,  even  though  slight,  generally  proves  of 
decided  service,  but  the  choice  of  locality  must  be  deter- 
mined ver)i  largely  by  the  personal  experience  of  the 
patient.  Many  sufferers  do  better  in  the  smoky  atmo- 
sphere of  cities  than  in  the  country,  but  a  dry  atmosphere 
with  a  moderate  elevation  is  better  suited  for  the  majority. 

Among  internal  remedies  none  has  proved  more  useful 
than  potassium  iodid  (5  to  10  grains  thrice  daily)  in  averting 
attacks.  Tincture  of  belladonna  (3  to  5  minims  thrice  daily) 
is  a  valuable  adjunct  to  the  iodid.  Arsenic  may  be  tried  when 
the  iodids  fail.  Grindelia  robusia  is  sometimes  useful  when 
there  is  much  catarrh.  Strychnin  is  of  service  in  cases  asso- 
ciated with  emphysema. 

TJie  Attack. — Some  patients  derive  great  benefit  from  the 
fumes  of  ignited  stramonium  or  belladonna  leaves  or  paper 
that  has  been  impregnated  with  potassium  nitrate.  These 
agents  may  be  burnt  in  the  patient's  room  or  smoked  in  a 
pipe  or  in  the  form  of  cigarets.  Marked  alleviation  of  the 
paroxysms  is  often  obtained  from  the  inhalation  of  amyl 
nitrite  (5   to  6  minims),  ethyl  iodid  (10  to   20  minims),  or 


236        DISEASES   OF  THE  RESPIRATORY  SYSTEM. 

a  few  whiffs  of  chloroform.  If  such  measures  fail  to 
afford  relief,  internal  remedies  must  be  used.  In  some 
cases  strong  hot  coffee  acts  most  happily ;  in  others  more 
benefit  is  derived  from  hot  whisky  and  water.  Among  the 
numerous  special  remedies  that  have  been  advocated  the 
following  appear  to  be  the  most  reliable  :  opium,  belladonna, 
bromids,  chloral,  paraldehyd,  Hoffmann's  anodyne,  lobelia, 
and  quebracho. 

Few  attacks  will  resist  the  action  of  morphin  hypoder- 
mically  with  atropin,  but  the  greatest  caution  must  be  ex- 
ercised in  order  that  the  patient  may  not  become  addicted 
to  the  drug.  Heroin  hydrochlorid  hypodermically,  in  doses 
of  from  3^  to  ^  grain,  may  often  be  substituted  for  morphin 
with  great  advantage.  When  the  attacks  are  associated 
with  bronchial  catarrh,  a  combination  like  the  following 
sometimes  proves  efficacious : 

R.      Tincturae  belladonnae f^j 

Tincturse  lobelise      .    , f^iij 

Extract!  aspidospermatis  fiuidi   .    .    .    .  f^ss 

Spiritus  setheris  compositi f^v 

Strontii  bromidi ,    .    .    .    ^^iiss 

Elixiris  aromatici q.  s.  ad  f^iv. — M. 

SiG. — A  dessertspoonful  in  water  every  two  or  three  hours. 

Among  other  measures  that  have  been  found  useful  in 
alleviating  asthmatic  attacks  may  be  mentioned  the  applica- 
tion of  sinapisms  to  the  chest,  the  inhalation  of  compressed 
air,  and  the  inhalation  of  oxygen, 

HAY   ASTHMA* 

(Hay-fever;  Autumnal  Catarrh ;  Rose-cold.) 

Definition. — A  catarrhal  affection  of  the  upper  air-pas- 
sages, characterized  by  coryza  and  asthmatic  seizures,  and 
evoked  by  irritation  of  a  hyperesthetic  nasal  mucous  mem- 
brane. 

^tiologfy. — An  inherited  tendency,  nervous  tempera- 
ment, indoor  life,  and  chronic  nasal  disease  are  predispos- 
ing factors.  The  attacks,  as  a  rule,  occur  in  the  autumn 
(autumnal  catarrh)  or  in  the  spring  (rose-cold),  and  are  ex- 
cited  by  certain   dusts,  vapors,  or  odors.     The  pollen   of 


PULMONARY  EMPHYSEMA.  237 

plants  seems  to  be  a  common  excitant.  The  seizures  may 
occur  at  any  time  if  the  peculiar  irritant  is  present. 

Pathology. — An  essential  feature  is  the  hypersensitive 
condition  of  the  mucous  membrane,  and  this  is  often,  though 
not  invariably,  associated  with  hypertrophic  rhinitis. 

Symptoms. — Redness  of  the  conjunctivae  and  swelling 
of  the  eyelids ;  pruritus  of  the  nose  and  eyes ;  sneezing ; 
obstruction  of  the  nostrils;  watering  of  the  eyes;  a  copious 
discharge  of  mucus  from  the  nose ;  headache ;  cough ;  and 
asthmatic  attacks  are  the  usual  phenomena. 

Rose-cold  usually  begins  in  May  or  June  and  runs  to  the 
latter  part  of  July.  Autumnal  catarrh  begins  in  the  latter 
part  of  August  and  ends  with  the  first  frost. 

Prognosis. — The  disease  never  proves  fatal,  but  perma- 
nent cure  is  very  rare. 

Treatment. — Careful  search  should  be  made  for  chronic 
nasal  disease,  and  if  found,  appropriate  treatment  instituted. 

A  change  of  climate  during  the  period  of  susceptibility 
exempts  most  patients.  A  sea-voyage  or  a  sojourn  in  some 
high-mountain  district,  like  the  White  Mountains,  Adiron- 
dacks,  Catskills,  or  Alleghanies,  may  be  recommended. 

Tonics  such  as  quinin,  arsenic,  and  strychnin  are  often 
very  useful  when  administered  before  and  during  an  attack. 
To  allay  itching  and  lacrimation  the  eyes  may  be  washed 
with  a  solution  of  boric  acid  (10  grains  to  the  ounce)  or 
sulphate  of  zinc  (i  to  2  grains  to  the  ounce).  Sneezing, 
nasal  fulness,  and  discharp;e  are  often  relieved  bv  medi- 
cated  sprays  (Dobell's  solution)  or  the  application,  on 
pledgets  of  cotton,  of  adrenalin  solution  (i  :  5000).  In  some 
cases  Dunbar's  poUantin  acts  very  favorably. 

PULMONARY  EMPHYSEMA* 

Definition. — Abnormal  distention  of  the  lungs  with  air. 

Varieties. — (i)  Interlobular  Emphysema. — This  form  is 
rare,  and  results  from  the  rupture  of  the  air-vesicles  and  the 
escape  of  air  into  the  interstitial  tissue. 

(2)  Compensatory  Emphysema. — This  is  a  vicarious  disten- 
tion of  one  part  of  the  lung,  owing  to  pathologic  changes  in 
another   part   of  the    organ.     It   is  primarily  physiologic, 


238         DISEASES   OF   THE   RESPIRATORY  SYSTEM. 

though  atrophy   of  the  walls  of  the  air-vesicles   may  ulti- 
mately ensue. 

(3)  Atrophic  or  Senile  Emphysema. — In  this  form  the 
capacity  of  the  air-vesicles  is  relatively  increased,  owing  to 
atrophy  of  the  solid  tissue. 

(4)  Hypertrophic  or  Substantive  Emphysema. — This  is  the 
ordinary  form  of  emphysema.  It  is  characterized  by  a  great 
enlargement  of  the  lungs  in  consequence  of  overdistention 
of  the  air-vesicles. 

Compensatory  emphysema,  atrophic  emphysema,  and  hy- 
pertrophic emphysema  together  form  a  subdivision  known 
as  vesicular  emphysema. 

HYPERTROPHIC  EMPHYSEMA. 

Definition. — A  pulmonary  disease  characterized  ana- 
tomically by  dilatation  of  the  air-vesicles  and  atrophy  of 
their  walls ;  and  clinically  by  permanent  enlargement  of  the 
thorax,  with  persistent  dyspnea. 

i^tiology. — Congenital  weakness  of  the  lung  structure — 
probably  a  defective  development  of  elastic  tissue — is  an 
important  predisposing  factor.  This  predisposition  may  be 
transmitted  through  several  generations. 

In  forced  expiration  the  air  cannot  escape  with  sufficient 
rapidity  through  the  narrow  glottis,  and  the  backward 
pressure  stretches  the  air-vesicles ;  hence  the  obstinate 
cough  of  chronic  bronchitis,  the  expiratory  straining  of 
asthma,  and  occupations  that  necessitate  forced  expiration, 
like  playing  on  wind-instruments  and  glass-blowing,  are 
causal  factors. 

Patholog"y. — The  lungs  are  enlarged  and  do  not  col- 
lapse when  the  thorax  is  opened.  In  bad  cases  the  free 
margins  are  studded  with  large  bullae  or  blebs  that  have 
resulted  from  the  rupture  of  a  number  of  vesicles  into  a 
common  sac.  The  organs  are  pale  and  have  a  soft,  cotton- 
like feel.  Microscopic  examination  reveals  atrophy  of  the 
vesicular  walls,  a  diminished  amount  of  elastic  tissue,  and 
more  or  less  obliteration  of  the  pulmonary  capillaries. 
This  last  condition  leads  to  increased  tension  in  the  pulmo- 


PULMONAR  V  EMPHYSEMA.  239 

nary  artery  and  to  secondary  hypertrophy  of  the  right  ven- 
tricle. 

Symptoms. — The  disease  generally  manifests  itself  in 
middle  life,  but  it  is  sometimes  observed  in  the  young. 
Dyspnea,  increased  by  exertion ;  cyanosis,  often  extreme 
during  attacks  of  acute  bronchitis ;  and  cough,  from  the 
associated  bronchitis,  are  the  usual  symptoms.  In  advanced 
cases  edema  of  the  feet  may  result  from  cardiac  failure. 

Physical  SigrtiS. — The  neck  is  short,  and  the  sterno- 
cleidomastoids are  prominent.  The  thorax  is  likewise 
short,  but  broad  especially  in  its  anteroposterior  diameter. 
This  configuration  has  given  rise  to  the  term  "barrel- 
shaped  "  chest.  On  respiration  there  is  little  expansion,  but 
an  elevation  of  the  thorax  as  a  whole.  The  apex-beat  is 
invisible,  but  an  abnormal  pulsation  is  often  noted  in  the 
epigastrium. 

Palpation. — Vocal  fremitus  is  diminished. 

Percussion. — This  gives  increased  resonance.  The  upper 
level  of  hepatic  dulness  is  depressed,  and  the  area  of  cardiac 
dulness  may  be  almost  obliterated. 

Auscultation, — Inspiration  is  short  and  feeble  ;  expiration 
is  prolonged  and  low  pitched,  or  inaudible.  Rales  resulting 
from  the  associated  bronchitis  are  frequently  heard.  The 
pulmonary  second  sound  is  accentuated. 

Complications. — Bronchitis,  asthma,  dilatation  of  the 
right  ventricle,  and,  later,  tricuspid  regurgitation  and  dropsy. 

Diagnosis. — Chronic  Bronchitis. — In  this  disease  there  is 
no  marked  dyspnea ;  the  chest  is  not  enlarged  ;  there  is  no 
change  in  the  percussion-note  or  in  the  expiratory  sound. 

Pneumothorax. — This  disease  develops  suddenly,  is  uni- 
lateral, and  yields  a  tympanitic  note  on  percussion  and 
metallic  tinkling  and  bell-tympany  on  auscultation. 

Prognosis. — Emphysema  is  incurable,  but  its  advance 
may  be  stayed  by  relieving  the  primary  condition.  It  runs 
a  long  course  and  is  in  itself  rarely  fatal,  but  death  may 
result  from  heart-failure  and  dropsy,  or  from  intercurrent 
pneumonia. 

Treatment. — The  treatment  advocated  in  chronic  bron- 
chitis and  asthma  is  often  applicable  here.    The  patient  should 


240        DISEASES   OE  THE   RESPIRATORY  SYSTEM. 

be  placed  under  the  most  favorable  hygienic  conditions. 
Iron  is  indicated  in  the  anemic.  Strychnin  {-^-^  to  -^  grain) 
is  a  valuable  respiratory  and  cardiac  stimulant,  and  may  be 
combined  with  digitalis  when  there  are  symptoms  of  heart- 
failure. 

R .     Strychninse  sulphatis  .,.»....  gr.  ss 

Pulveris  digitalis 

Pulveris  scillae 

Ferri  reducti     .....    o..=    aa  gr.  xx. — M. 
Fiant  pilulas  No.  xx. 
SiG. — One  thrice  daily. 

The  inhalation  of  oxygen,  or  the  inspiration  of  compressed 
air,  followed  by  expiration  into  rarefied  air,  is  sometimes  a 
useful  measure. 

HEMOPTYSIS* 

(Bronchorrhagia ;  Bronchopulmonary  Hemorrhage.) 

Definition. — The  expectoration  of  blood. 

i^tiolog'y. — The  chief  causes  are  :  (i)  Traumatism.  (2) 
Certain  organic  diseases  of  the  lung,  especially  tuberculosis, 
lobar  pneumonia,  bronchiectasis,  gangrene,  infarct,  and  can- 
cer. (3)  Passive  congestion  the  result  of  heart  disease, 
especially  mitral  lesions.  (4)  Rupture  of  an  aortic  aneur- 
ysm. (5)  Diseases  profoundly  affecting  the  blood,  such  as 
purpura,  hemophilia,  scurvy,  and  leukemia.  (6)  Ulcers, 
traumatic,  syphilitic,  or  malignant,  of  the  trachea  or  larynx. 
(7)  Vicarious  menstruation  (very  rare). 

Symptoms. — Sometimes  the  bleeding  is  preceded  by 
cough,  dyspnea,  or  substernal  warmth  or  tenderness,  but 
often  there  is  no  premonition,  and  the  first  indication  is  the 
presence  of  a  warm  salty  fluid  in  the  mouth.  The  blood  is 
generally  raised  by  coughing,  and  is  bright  red  and  frothy. 
It  is  alkaline  in  reaction,  and  intimately  mixed  with  air  and 
mucus.  The  hemorrhage  is  rarely  profuse  unless  it  results 
from  the  rupture  of  an  aortic  aneurysm  or  the  ulceration  of 
a  large  vessel  in  advanced  phthisis.  Auscultation  of  the 
chest  reveals  bubbling  rales.  The  subsequent  expectora- 
tions are  tinged  with  blood,  and  if  much  is  swallowed,  it 
may  excite  vomiting  or  pass  into  the  intestine  and  impart  a 
tarry  appearance  to  the  stools. 


HEMORRHAGIC  INFARCT  OF  THE   LUNG.  24 1 

Diagnosis. — The  differential  diagnosis  between  hemat- 
entesis  and  hemoptysis  has  been  considered  on  page  63. 

Prognosis. — This  depends  upon  the  cause.  It  is  rarely 
fatal,  except  in  aneurysm  and  in  advanced  phthisis  with  a 
large  cavity. 

Treatment. — Absolute  rest  is  essential.  An  ice-bag 
may  be  placed  over  the  suspected  seat  of  the  hemorrhage,  but 
it  should  be  removed  if  it  aggravates  the  coughing.  Bits 
of  ice  may  be  given  to  the  patient  to  suck.  There  is  no 
more  useful  remedy  than  morphin,  which  serves  to  allay 
excitement  and  to  check  cough.  It  is  best  given  hypoder- 
mically.  The  application  of  firm  ligatures  to  the  limbs  may 
prove  efficacious  by  lowering  the  intrapulmonary  pressure. 
When  the  hemorrhage  is  protracted,  a  saline  purge  is  some- 
times useful.  Among  other  remedies  that  seem  to  be  of 
service  may  be  mentioned  oil  of  erigeron,  fluid  extract  of 
hamamelis,  and  gelatin.  Ergot  is  useless,  and  so  is  the 
inhalation  of  vaporized  solutions  of  astringent  drugs. 

HEMORRHAGIC  INFARCT  OF  THE  LUNG. 
(Pulmonary  Apoplexy.) 

Definition. — A  circumscribed  area  of  necrosis  infiltrated 
with  blood. 

!]^tiology. — The  most  common  cause  of  pulmonary 
infarct  is  obstruction  of  a  branch  of  the  pulmonary  artery 
by  an  embolus  coming  from  the  right  heart  or  the  general 
venous  system.  In  some  cases  the  obstruction  is  caused  by 
a  thrombus,  the  formation  of  which  has  been  favored  by 
cardiac  weakness. 

Pathology. — The  infarct  is  usually  located  in  the  per- 
iphery of  the  lung  ;  it  is  conic  in  shape,  with  its  apex  point- 
ing inward.  The  portion  affected  is  firm,  airless,  and  of  a 
dark-red  color.  Microscopic  examination  shows  a  dense 
aggregation  of  blood-corpuscles. 

If  the  process  lasts  long  enough,  the  dead  tissue  and 
blood  are  slowly  absorbed  and  replaced  by  a  cicatrix. 

Symptoms. — When  the  infarct  is  large,  the  usual  symp- 
toms are  dyspnea,  cough,  and  the  expectoration   of  dark 

16 


242        DISEASES   OF  THE  RESPIRATORY  SYSTEM. 

blood  containing  few  air-bubbles.  These  symptoms  occur- 
ring in  chronic  heart-disease  are  especially  suggestive. 

Physical  Signs. — Very  large  infarcts  may  give  dulness 
and  bronchial  breathing. 

Treatment. — The  condition  itself  is  not  amenable  to 
treatment.  Remedies  should  be  directed  to  the  primary 
disease. 

CONGESTION  OF  THE  LUNGS. 
ACTIVE  CONGESTION, 

etiology. — This  results  from  an  increased  afflux  of  blood 
to  the  lungs.  Violent  exercise,  mountain  climbing,  and  the 
inhalation  of  irritants  may  produce  it.  It  is  an  associated 
condition  in  all  severe  inflammatory  diseases  of  the  lungs. 
In  the  vast  majority  of  cases  it  marks  the  initial  stage  of 
croupous  pneumonia. 

Pathology. — The  lung  is  bright  red  in  color,  heavy,  and 
less  crepitant.  When  incised  and  pressed,  copious  frothy 
blood  exudes. 

Symptoms. — The  chief  symptoms  are  dyspnea  ;  a  short, 
dry  cough,  followed  by  frothy,  blood-streaked  sputum ; 
and  a  rapid,  full  pulse.  The  presence  of  fever  indicates 
commencing  pneumonia. 

Physical  examination  reveals  slight  dulness,  crepitant  rales, 
and  bronchovesicular  breathing. 

Treatment. — The  measures  most  likely  to  effect  deple- 
tion of  the  lung  are  complete  rest,  the  application  of  dry  or 
wet  cups  to  the  chest,  and  the  administration  of  veratrum 
viride  and  a  saline  purge. 

PASSIVE  CONGESTION. 

!^tiology. — This  results  from  obstruction  to  the  flow  of 
blood  from  the  lungs  to  the  heart.  The  chief  cause  is  car- 
diac disease,  especially  lesions  of  the  mitral  valves  and  weak- 
ness of  the  left  ventricle  from  fatty  or  fibroid  changes. 

Pathology. — The  lungs  are  dark  red  in  color,  and  often 
somewhat  edematous.  When  the  condition  has  lasted  a 
long  time,  the  organs   become   brown,  dense,  and   tough 


CONGESTION  OF  THE   LUNGS.  243 

(brown  induration).  Microscopic  examination  reveals  dila- 
tation of  the  capillaries,  overgrowth  of  connective  tissue, 
brown  pigmentation,  and  degenerative  changes  in  the  blood- 
vessels. 

Symptoms. — Dyspnea,  cough,  and  the  expectoration  of 
blood-stained  mucus  containing  pigmented  epithelial  cells 
are  the  characteristic  symptoms.  Physical  examination  re- 
veals slight  dulness,  feeble  breathing,  and  abundant  fine 
rales. 

Treatm.ent. — Remedies  should  be  directed  to  the  under- 
lying cardiac  disease.  The  appHcation  of  dry  or  wet  cups 
often  gives  temporary  relief  When  the  symptoms  are  ur- 
gent, venesection  is  indicated.  Saline  and  mercurial  aperi- 
ents are  of  service. 

HYPOSTATIC  CONGESTION, 
(Hypostatic  Pneumonia ;  Splenization  of  the  Lung.) 

Definition. — A  congestion  of  dependent  portions  of  the 
lungs  occurring  in  asthenic  diseases  that  necessitate  a  pro- 
tracted recumbent  position. 

Ktiology. — It  is  generally  observed  in  low  fevers  and  in 
chronic  wasting  diseases.  Cardiac  weakness,  recumbent 
posture,  and  alterations  in  the  blood  are  the  causal  factors. 

Pathology. — The  lungs  are  dark  red  and  edematous  pos- 
teriorly. The  edema  and  increased  amount  of  blood  render 
the  organs  more  solid  and  less  crepitant.  They  never  show 
the  granular  appearance  of  croupous  pneumonia. 

Symptoms. — The  symptoms  are  often  indefinite.  There 
may  be  moderate  dyspnea,  slight  cyanosis,  cough,  and,  per- 
haps, blood-tinged  expectoration. 

Physical  examination  reveals  dulness  over  the  lower  lobes, 
subcrepitant  rales,  and  feeble,  blowing  breathing. 

Treatment. — Efforts  should  be  made  to  prevent  the 
development  of  hypostatic  pneumonia  in  asthenic  diseases 
by  frequent  change  of  posture  and  the  timely  administration 
of  such  stimulants  as  strychnin,  digitalis,  alcohol,  ammonia, 
and  camphor.  When  already  present,  relief  is  sometimes 
afforded  by  dry  or  wet  cupping  or  the  application  of  stupes. 


244        DISEASES   OF   THE   RESPIRATORY  SYSTEM. 

EDEMA  OF  THE  LUNGS. 

Definition. — An  effusion  of  serous  fluid  into  the  air- 
vesicles  and  interstitial  tissue  of  the  lungs. 

etiology. — (i)  It  is  frequently  caused  by  passive  hypere- 
mia, the  result  of  chronic  heart  disease.  (2)  It  may  be  a  part 
of  a  general  dropsy  induced  by  Bright's  disease.  (3)  It  is 
a  common  cause  of  death  in  conditions  that  lead  to  heart- 
failure,  such  as  grave  anemia,  cerebral  lesions,  and  acute 
infections. 

Local  pulmonary  edema  is  often  found  around  abscesses, 
infarcts,  and  areas  of  consolidation. 

Patllolog"y. — The  lungs,  especially  the  dependent  por- 
tions, are  heavy,  red  in  color,  and  boggy  to  the  feel.  When 
the  affected  portion  is  incised  and  subjected  to  pressure,  abun- 
dant blood-stained,  frothy  serum  exudes. 

Symptoms. — These  consist  in  dyspnea,  cyanosis,  cough, 
and  the  expectoration  of  large  quantities  of  frothy,  serous 
fluid.  Occasionally  the  sputum  is  blood-stained.  The  skin 
is  often  cold  and  livid.     There  is  no  fever. 

Physical  examination  reveals  feeble  tactile  fremitus,  dul- 
ness,  weak  breath-sounds,  and  numerous  fine,  moist  rales. 

Diagnosis^ — Croupous  Pneumonia. — This  is  characterized 
by  a  chill,  fever,  pain,  rusty  expectoration,  and  signs  of  con- 
solidation. 

Hydrothorax. — In  this  condition  there  may  be  enlargement 
of  the  affected  side,  with  displacement  of  the  apex-beat. 
The  upper  level  of  dulness  is  often  movable,  and  frothy 
sputum  and  rales  are  absent. 

Prognosis. — Always  grave.  It  is  often  a  terminal  symp- 
tom of  the  disease  in  which  it  occurs.  When  not  far  ad- 
vanced, and  the  primary  disease  is  amenable  to  treatment,, 
recovery  may  follow. 

Treatment. — When  there  is  much  cyanosis  and  the 
patient's  strength  will  permit  it,  the  application  of  wet  cups 
to  the  chest  or  bleeding  from  the  arm  is  of  great  value. 
Hot  fomentations  should  be  applied  to  the  chest.  Hydra- 
gogue  cathartics  are  indicated.  Epsom  salts  in  concen- 
trated  solution    or  elaterium  (  \  grain)   may  be   selected. 


CROUPOUS  PNEUMONIA.  245 

Cardiac  stimulants  like  alcohol,  ammonia,  camphor,  digitalis, 
and  especially  strychnin  are  required  and  may  be  given 
hypodermically. 

Caffein  is  a  useful  diuretic  and  cardiac  and  respiratory 
stimulant. 

CROUPOUS  PNEUMONIA* 

(Lobar  Pneumonia;  Pneumonitis;  Lung  Fever.) 

Definition. — An  acute  specific  disease,  characterized  ana- 
tomically by  an  inflammation  of  the  lungs,  followed  by  a 
rapid  infiltration  of  their  alveoli,  and  manifested  clinically 
by  high  fever,  cough,  dyspnea,  "  rusty  "  sputum,  and  phy- 
sical signs  indicative  of  consolidation. 

l^tiology. — Age,  sex,  and  chmate  exert  but  little  pre- 
disposing influence.  Lowered  vitality  from  bad  hygienic 
surroundings  or  from  some  preexistent  disease,  like  dia- 
betes, Bright's  disease,  or  one  of  the  infectious  fevers,  favors 
its  development.  One  attack  renders  the  patient  more 
liable  to  subsequent  infection.  Alcoholism  is  a  strong  pre- 
disposing factor.  Exposure  to  cold  and  wet  often  precipi- 
tates the  attack. 

The  exciting  cause  is  the  invasion  of  the  lung  by 
pathogenic  bacteria,  especially  by  Frankel's  Diplococcus 
pneumoniae. 

Pathology. — Anatomically  three  stages  have  been  rec- 
ognized:  (i)  That  of  congestion;  (2)  that  of  red  hepatiza- 
tion ;  (3)  that  of  gray  hepatization. 

Stage  I. — The  affected  portion  remains  distended  when 
the  chest  is  opened  ;  it  is  of  a  deep-red  color,  and  is  more 
resistant  to  the  touch  than  the  normal  lung.  On  section,  a 
frothy,  blood-stained  serum  freely  exudes.  Microscopic 
examination  reveals  a  dilated  and  tortuous  condition  of  the 
capillaries,  swelling  of  the  alveolar  cells,  and  a  slight  cor- 
puscular exudate. 

Stage  2, — The  hepatized  portion  is  increased  in  volume, 
is  quite  firm,  is  of  a  dark-red  color,  and  so  heavy  that  it 
sinks  in  water.  It  is  very  friable,  and  the  torn  surface  is 
dry  and  presents  a  granular  appearance,  owing  to  the  pro- 
jection of  fibrinous  plugs  from  the  alveoH. 


246         DISEASES   OF  THE   RESPIRATORY  SYSTEM. 

Microscopic  examination  reveals  a  mesh  of  coagulated 
fibrin  inclosing  numerous  red  blood-corpuscles  and  some 
leukocytes.  The  latter  are  also  noted  in  the  interlobular 
tissue.  In  sections  properly  treated  the  diplococcus  is 
detected. 

Stage  J. — The  red  color  gives  place  to  a  mottled  gray, 
and  the  solidified  area  begins  to  soften.  The  change  in 
color  is  due  to  the  compression  of  the  capillaries,  to  the 
disappearance  of  red  corpuscles  and  their  replacement  by 
leukocytes,  and  to  fatty  degeneration  of  some  of  the  ele- 
ments. 

The  consolidation  usually  begins  at  the  base  and  extends 
upward.  The  most  frequent  seat  is  the  lower  lobe  of  the 
right  lung.  The  bronchi  and  the  adjacent  pleura  are  in- 
volved in  the  inflammatory  process. 

Events.  —  Resolution  commonly  occurs,  the  exudate 
being  removed  rapidly  by  absorption.  Death  may  occur 
at  any  period  of  the  disease  from  general  toxemia,  the 
severity  of  which  is  often  altogether  disproportionate  to  the 
area  of  lung  involved ;  from  dilatation  of  the  right  ven- 
tricle ;  from  asphyxia  ;  or  a  pneumococcic  complication,  such 
as  meningitis  or  endocarditis. 

Abscess,  gangrene,  and  chronic  interstitial  pneumonia 
are  rare  terminations. 

Symptoms. — The  disease  usually  begins  with  a  decided 
chill  and  a  sharp  pain  in  the  side,  followed  by  a  rapid  rise 
of  temperature.  The  latter  often  attains  its  maximum  (104°- 
105°  F.)  in  twenty-four  hours,  and  generally  continues 
high,  with  slight  diurnal  remissions,  until  the  fifth,  seventh, 
ninth,  or  eleventh  day,  when  it  falls  by  crisis,  frequently 
reaching  the  norm  within  twenty-four  hours.  Occasionally 
the  temperature  falls  by  lysis.  There  is  marked  dyspnea  ; 
the  respirations  are  shallow  and  rapid,  ranging  from  40  to  80 
a  minute,  thus  making  the  ratio  between  the  respiration  and 
the  puke  as  i  is  to  3  or  as  i  is  to  2.  Congh  is  a  prominent 
symptom:  at  first  it  is  short  and  dry,  but  later  it  is  accom- 
panied by  bloody  or  rnsty  translucent  and  tenacious  sputa. 
Microscopically  the  sputum  contains  red  blood-corpuscles, 
free  pigment,  pus-corpuscles,  diplococci,  and   other  micro- 


CROUPOUS  PNEUMONIA.  247 

organisms.  The  face  is  flushed ;  the  Hps  are  cyanosed  and 
often  the  seat  of  a  herpetic  eruption ;  the  tongue  is  heavily 
furred ;  the  bowels  are  constipated ;  the  urine  is  scanty, 
high-colored,  deficient  in  chlorids,  and  often  sHghtly  albu- 
minous. In  severe  cases  delirium  is  rarely  absent.  Exam- 
ination of  the  blood  usually  shows  marked  leukocytosis. 

Physical  Signs. — Inspection. — There  may  be  deficient 
expansion  over  the  affected  side.  There  is  no  bulging  of 
the  interspaces  nor  displacement  of  the  apex-beat. 

Palpation. — In  the  vast  majority  of  cases  the  vocal  frem- 
itus is  considerably  increased  over  the  affected  area. 

Percussion. — In  the  earliest  stage  there  may  be  hyperreso- 
nance  from  diminished  intrapulmonary  tension.  As  con- 
solidation advances,  however,  the  note  becomes  remarkably 
dull.  Percussion  over  unaffected  lobes  yields  hyperreso- 
nance  or  tympany. 

Auscultation. — In  the  stages  of  congestion  fine  crepitant 
rales  are  heard  at  the  end  of  full  inspiration.  They  are 
probably  produced  by  the  forcible  separation  of  adherent 
vesicular  walls.  In  the  stage  of  consoHdation  auscultation 
reveals  exaggerated  vocal  resonance  and  bronchial  breath- 
ing. During  resolution  the  softening  of  the  exudate  gives 
rise  to  fine  moist  rales — the  redux  crepitus. 

Atypical  Cases. — Senile  Pneuinojiia. — The  symptoms  often 
develop  insidiously;  the  temperature  may  not  be  high; 
the  pulse  may  not  be  accelerated ;  expectoration  is  often 
absent ;  the  signs  are  not  marked ;  dehrium  is  common ; 
weakness  is  extreme  ;  and  death  from  exhaustion  is  the 
most  frequent  termination. 

Pneumonia  in  Children. — It  is  often  ushered  in  with  con- 
vulsions. Headache,  delirium,  stupor,  and  coma  are  promi- 
nent symptoms,  so  that  the  disease  may  simulate  meningitis. 
The  temperature  is  vei'y  high  ;  expectoration  is  often  absent. 
The  disease  frequently  begins  at  the  apex  of  the  lung. 

Typhoid  Pneumonia. — In  this  form  there  are  pronounced 
typhoid  symptoms — headache,  muttering  delirium,  stupor, 
a  dry,  brown  tongue,  subsultus  tendinum,  ca~rphologia,  a 
rapid,  weak  pulse,  and  high  fever.  The  expectoration  may 
resemble  prune-juice. 


248         DISEASES   OF   THE   RESPIRATORY  SYSTEM. 

Pneumonia  of  Drunkards. — The  onset  is  often  gradual ;  the 
dyspnea  is  marked  ;  the  temperature  is  not  high ;  violent 
maniacal  dehrium  commonly  develops  ;  and  death  from  ex- 
haustion is  exceedingly  frequent. 

Massive  Pneumonia. — In  this  form  the  bronchi,  as  well  as 
the  air-vesicles,  are  filled  with  fibrinous  exudate.  The  phy- 
sical signs  resemble  those  of  pleural  effusion. 

Central  Pneumonia. — In  this  form  the  inflammatory  proc- 
ess commences  in  the  center  of  a  lobe,  and  in  consequence 
the  characteristic  physical  signs  may  not  manifest  them- 
selves for  two  or  three  days. 

Migratory  Pneumonia. — In  this  type  the  specific  inflam- 
mation shows  a  tendency  to  spread  and  to  involve  success- 
ively fresh  areas  of  lung  tissue. 

Complications. — These  are  usually  due  to  pneumococcic 
infection.  Pleurisy  is  the  most  common  complication.  It 
may  be  either  serous  or  purulent.  Pericarditis  and  endo- 
carditis are  not  very  infrequent.  The  latter  is  often  ulcerative 
in  type.  Among  less  frequent  complications  may  be  men- 
tioned meningitis,  arthritis,  parotitis,  nephritis,  jaundice,  and 
delayed  resolution  (consolidation  may  last  for  five  or  six 
weeks  and  then  gradually  disappear).  Abscess,  gangrene, 
and  chronic  interstitial  pneumonia  are  rare  sequels. 

Diagnosis. — Pleurisy. — There  is  rarely  a  distinct  chill ; 
fever  is  not  so  high  nor  the  pulse  so  rapid ;  there  is  no 
rusty  sputum ;  nervous  symptoms  are  wanting ;  there  is 
often  bulging  of  the  interspaces,  with  displacement  of  the 
apex-beat;  the  level  of  dulness  may  change  with  the  pos- 
ture of  the  patient ;  vocal  fremitus  and  vocal  resonance  are 
diminished;  and  the  breath-sounds  are  generally  weak  and 
distant. 

Acute  Phthisis. — The  history,  the  mode  of  onset,  the  long 
duration,  the  remittent  fever,  the  rapid  emaciation,  profuse 
sweats,  and  presence  of  tubercle  bacilli  and  elastic  fibers 
in  the  sputum  will  suggest  phthisis. 

Pulmonary  Edema. — In  edema  there  is  absence  of  chill, 
fever,  and  pain ;  the  expectoration  is  frothy  and  serous ; 
both  lungs  are  commonly  affected ;  auscultation  reveals 
abundant  subcrepitant  rales  and  weak  breathing. 


CROUPOUS  PNEUMONIA.  249 

Typhoid  Fever. — Typhoid  pneumonia  may  readily  be  mis- 
taken for  typhoid  fever  with  pneumonia ;  but  pneumonia 
as  a  compHcation  occurs  late  in  the  disease,  so  that  the 
history  of  the  onset  gives  much  assistance. 

Prognosis. — In  young,  robust  subjects  of  good  habits 
the  prognosis  is  good.  After  the  age  of  sixty  the  outlook 
is  grave.  In  drunkards  the  disease  is  especially  fatal.  The 
coexistence  of  heart  or  kidney  disease  makes  pneumonia 
exceedingly  dangerous. 

In  individual  cases  continued  high  fever  (above  103.5°  F.), 
a  pulse  more  rapid  than  120  a  minute,  severe  nervous  symp- 
toms, extensive  consolidation,  and  absence  of  leukocytosis 
are  unfavorable  factors.  The  average  mortality  is  about  20 
per  cent. 

Treatment. — The  temperature  of  the  sick-room  should 
be  between  65°  and  70°  F.  The  diet  should  be  fluid  or 
semifluid.  Milk,  junket,  wine-whey,  broths,  eggs,  and  gruel 
are  suitable  forms  of  nourishment.  Cool  water  should  be 
given  freely.  In  the  absence  of  any  indication  for  special 
local  treatment  the  chest  may  be  enveloped  in  a  cotton 
jacket. 

In  robust  subjects,  at  the  very  onset,  when  the  invasion  is 
violent  and  attended  with  a  bounding  pulse,  marked  dyspnea, 
and  severe  pleuritic  pain,  the  abstraction  of  from  10  to  20 
ounces  of  blood  may  afford  great  relief.  Later  in  the  course 
of  the  disease,  if  cyanosis  and  orthopnea  develop  in  conse- 
quence of  overdistention  of  the  right  ventricle,  venesection 
may  also  prove  useful. 

Cardiac  Weakness. — Alcohol  is  the  best  stimulant.  When 
the  pulse  becomes  compressible  and  the  diastolic  sound  at 
the  pulmonary  area  loses  its  force,  it  should  be  given  freely. 
The  patients  who  need  it  most  are  the  old,  the  debilitated, 
and  the  alcoholic.  Digitalis  is  undoubtedly  useful  in  some 
cases,  but  its  action  is  uncertain  and  often  disappointing. 

As  a  circulatory  stimulant  strychnin  generally  proves 
much  more  efficacious  than  digitalis.  It  should  be  given  in 
ascending  doses  of  from  ^^  to  ^3^  of  a  grain.  In  order  that 
there  may  be  immediate  absorption,  large  doses  should 
always  be  given  hypodermically.    Caffein  is  a  useful  adjuvant 


250        DISEASES   OF   THE   RESPIRATORY  SYSTEM. 

to  strychnin,  but  it  should  not  be  used  when  there  is  marked 
insomnia.  In  threatening  collapse  camphor  hypodermically 
(i  to  2  grains  in  sterile  olive  oil  every  two  or  three  hours)  is 
very  efficient.  Subcutaneous  injections  of  normal  salt  solu- 
tion have  also  been  found  useful  in  overcoming  adynamia. 

Pain. — Morphin  hypodermically  is  the  best  analgesic. 
Hot  or  cold  applications  are  useful.  When  the  pain  is  very 
severe,  a  few  wet  cups,  followed  by  poultices,  will  be  found 
serviceable. 

Cough. — Hard,  dry  cough  is  best  relieved  by  codein  (-^  to 
\  grain),  heroin  (y^g-  grain),  or  Dover's  powder  (3  to  5  grains). 
Expectorants  are  rarely  needed.  When,  however,  there  is 
much  bronchial  catarrh,  ammonium  carbonate  may  be  given 
to  facilitate  expectoration. 

Fever. — Persistent  high  fever  is  best  controlled  by  the 
application  of  ice-bags  to  the  affected  side,  cold  sponging,  or 
cool  baths. 

Dyspnea. — Cardiac  and  respiratory  stimulants  (strychnin, 
caffein,  ammonia)  are  of  service.  Oxygen  makes  the  breath- 
ing easier,  lessens  cyanosis,  and  conduces  to  sleep,  and  to 
this  extent  aids  in  conserving  energy. 

Insomnia  and  Delirium. — Opium  is  generally  the  best 
sedative.  Of  course  it  should  not  be  used  when  there  is 
extreme  dyspnea  or  when  there  are  evidences  of  pulmonary 
edema.     Bromids  or  chloralamid  may  be  tried. 

Delayed  Resolution. — Small  blisters  may  be  applied  over 
the  affected  area,  and  potassium  iodid  may  be  administered 
internally. 

R.    Ammonii  iodidi ,^j 

Ammonii  chloridi giss 

Misturse  glycyrrhizse  compositae    ....  f^vj. — M. 

SiG. — A  tablespoonful  in  water  four  times  a  day. 

CATARRHAL  PNEUMONIA. 

(Capillary  Bronchitis;  Bronchopneumonia;  Lobular  Pneumonia.) 

Definition. — An  inflammation  of  the  terminal  bronchioles 
and  air-vesicles. 

Ktiology. — It  is  most  frequently  observed  in  the  very 
young  and  the  old.     It  is  a  common  sequel  of  the  specific 


CATARRHAL   PNEUMONIA.  25  I 

fevers,  especially  of  whooping-cough,  measles,  influenza,  and 
diphtheria.  In  debilitated  subjects  it  may  occur  as  a  primary 
affection,  the  result  of  exposure. 

Another  group  of  cases  results  from  the  aspiration  of 
particles  of  food  into  the  smaller  bronchi  (aspiration  or 
deglutition  pneumonia).  This  accident  is  liable  to  occur 
whenever  the  sensibility  of  the  larynx  is  benumbed,  as  in 
apoplexy,  bulbar  palsy,  or  uremia.  Cancer  of  the  throat  and 
operations  on  the  upper  air-passages  also  favor  its  occur- 
rence. 

The  immediate  cause  is  some  bacterium.  The  organism 
most  frequently  found  is  the  Diplococcus  pneumoniae.  This 
may  occur  alone  or  in  combination  with  the  streptococcus, 
staphylococcus,  bacillus  of  Friedlander,  or  more  rarely  with 
the  typhoid  bacillus,  influenza  bacillus,  colon  bacillus,  or 
diphtheria  bacillus. 

Pathology. — As  a  rule,  both  lungs  are  involved.  On 
section,  small  projecting  areas  of  consoHdation  are  noted 
here  and  there  around  the  finer  bronchioles.  Recent  patches 
are  reddish-brown  in  color,  firm,  and  smooth  or  finely  granu- 
lar ;  later  they  become  grayish  and  soft.  The  terminal 
bronchi  are  filled  with  purulent  material. 

In  addition  to  these  solidified  areas  there  are  other  small 
patches  of  collapsed  lung  that  are  airless,  firm,  and  bluish- 
red  in  color.  The  collapse  has  resulted  from  occlusion  of 
the  bronchus,  and  closely  resembles  consolidation  ;  but  it 
can,  as  a  rule,  be  overcome  when  inflation  is  practised  by 
means  of  a  blowpipe  inserted  in  the  supplying  bronchus. 

Microscopic  examination  reveals  an  exudate  in  the  ter- 
minal bronchi  and  air-cells,  which  is  composed  of  leukocytes 
and  desquamated  epithelium  in  various  stages  of  degenera- 
tion. The  walls  of  the  bronchioles  are  also  infiltrated  with 
leukocytes. 

When  compared  with  croupous  pneumonia,  the  contrast  is 
striking.  In  the  latter  the  lung  is  involved  en  masse ;  the 
consolidation  is  distinctly  granular,  and  the  exudate  is  com- 
posed of  red  blood-corpuscles,  white  blood-corpuscles,  and 
fibrin ;  the  Hning  epithelium  is  but  slightly  involved,  and  the 
walls  of  the  bronchi  are  not  infiltrated  with  leukocytes. 


252         DISEASES   OF  THE   RESPIRATORY  SYSTEM. 

Terminations. — (i)  Resolution;  the  exudate  undergoes 
fatty  degeneration  and  is  eventually  absorbed  or  expectorated. 

(2)  Death  frequently  occurs  from  asphyxia  or  exhaustion. 

(3)  Termination  in  tuberculosis  was  supposed  formerly  to 
occur  very  frequently  ;  it  is  now  regarded  as  being  relatively 
rare.  Most  of  the  cases  in  which  this  termination  is  sup- 
posed to  have  occurred  were  in  reality  cases  of  primary 
tuberculous  pneumonia.  (4)  Abscess,  gangrene,  and  chronic 
interstitial  pneumonia  are  occasional  sequels. 

Symptoms. — The  symptoms  are  often  masked  by  the 
primary  disease.  The  onset  is  usually  gradual,  and  is 
characterized  by  prostration,  cough,  and  fever.  The  last  is 
moderately  high  and  very  irregular  (ioi°-i04°  F.).  The 
dyspnea  is  marked,  and  the  respirations  are  rapid — 50  to  80 
a  minute;  the  pulse  is  greatly  accelerated — 120  to  180  a 
minute ;  cough  is  painful  and  accompanied  by  a  mucopuru- 
lent expectoration  that  is  rarely  blood-streaked.  The  face  is 
usually  pale  and  anxious,  and  the. lips  blue. 

Physical  Signs. — As  the  areas  of  consolidation  are  gen- 
erally small  and  scattered,  the  physical  signs  are  not  marked. 

Inspection  reveals  evidences  of  dyspnea — lividity,  playing 
of  the  nostrils,  prominence  of  the  sternocleidomastoids,  and 
perhaps  retraction  of  the  base  of  the  chest. 

Palpation  usually  gives  negative  results. 

Percussion  may  reveal  areas  of  dulness  in  one  or  both 
lungs. 

Auscultation  reveals  whistling  and  subcrepitant  rales  and 
areas  over  which  the  breathing  is  bronchial  or  broncho- 
vesicular. 

Diagnosis.— Acute  Phthisis. — In  this  disease  there  is  a 
tuberculous  bronchopneumonia  which  is  difficult  to  dis- 
tinguish from  simple  bronchopneumonia.  A  family  history 
of  tuberculosis,  extensive  involvement  of  the  apices,  bub- 
bling rales  indicating  softening,  the  long  duration,  profuse 
sweats,  rapid  emaciation,  and  the  presence  of  tubercle  bacilli 
and  elastic  fibers  in  the  sputa  are  the  diagnostic  phenomena 
of  phthisis. 

The  following  table  will  show  the  clinical  differences 
between  catarrhal  and  croupous  pneumonia : 


CATARRHAL  PNEUMONIA.                             253 

Catarrhal  Pneumonia.  Croupous  Pneumonia. 

Usually  secondary  to  bronchitis  or  an  Usually  a  primary  disease. 
acute  infectious  disease. 

The    onset  is  gradual  and  without  a  The  onset  is  abrupt  and  with  a  dis- 

distinct  chill.  tinct  chill. 

The    fever   is   moderately  high,    very  The   fever  is  high,  regular,  and  gen- 
irregular,  and  ends  by  lysis  after  an  erally  ends   by    crisis    between    the 
indefinite  period,  sometimes  of  two  sixth  and  ninth  day. 
or  three  weeks'  duration. 

The  sputum  is  mucopurulent  or  glairy  The  sputum  is  rusty  and  translucent, 
and  tenacious. 

Both  lungs  are  commonly  affected.  In  the  majority  of  cases  only  one  lung 

is  affected. 

The  physical  signs  are  indistinct  and  The  physical  signs  are  distinct  and 
indicate  scattered  areas  of  consoli-  indicate  a  large  uniform  consoli- 
dation, dation. 


Bronchitis. — In  simple  bronchitis  the  fever  is  not  high ; 
the  dyspnea  is  slight,  there  is  little  prostration,  and  there  are 
no  signs  of  consolidation. 

Prognosis. — In  previously  healthy  children  the  prog- 
nosis is  good.  In  cachectic  children  the  outlook  is  very 
grave.  Aspiration  pneumonia  is  generally  fatal.  The  average 
mortality  is  about  35  per  cent. 

The  duration  of  the  disease  is  from  one  to  three  weeks  ;  a 
longer  duration  should  suggest  tuberculosis. 

Treatment. — Much  can  be  done  by  careful  management 
in  preventing  bronchitis  from  gaining  access  to  the  smaller 
bronchi. 

On  the  supervention  of  catarrhal  pneumonia  the  patient 
should  be  confined  to  bed,  and  the  temperature  of  the  room 
maintained  between  6%"^  and  70°  F.  The  atmosphere  should 
be  rendered  moist  with  steam.  The  diet  should  be  liquid 
and  nutritious. 

Alcohol  is  often  required.  When  the  circulatory  de- 
pression is  pronounced,  whisky  may  be  given  in  doses  of 
from  10  to  30  minims  in  milk  to  a  child  of  two  years  every 
two  or  three  hours. 

At  the  outset  it  is  advantageous  to  administer  a  mild  pur- 
gative, preferably  calomel  or  castor  oil.  A  jacket  of  cotton- 
wool should  be  worn  throughout  the  attack.  When  there 
is   a   harsh,  dry  cough,  the   application    of  the  tincture  of 


254        DISEASES   OF   THE   RESPIRATORY  SYSTEM. 

iodin  of  suitable  strength  generally  affords  some  relief  In 
adults  sinapisms  or  stupes  may  be  used  instead  of  the  iodin. 
Fever  is  best  controlled  by  cold.  Compresses  wrung  out 
of  cold  water  may  be  wrapped  around  the  chest  and  changed 
for  fresh  ones  at  intervals  of  twenty  minutes.  Expectorants 
are  usually  required.  In  the  early  stage  potassium  citrate  is 
very  serviceable.  It  may  often  be  combined  advantageously 
with  spirit  of  nitrous  ether  and  ammonium  acetate,  as  in  the 
following  formula : 

R.     Potassii  citratis ^iss 

Spiritus  getheris  nitrosi fgvj 

Liquoris  ammonii  acetatis £3] 

Syrupi  tolutani 

Aquae .    .    aa  q.  s.  ad  f^^iv. — M. 

SiG. — Dessertspoonful   every   three    hours    for  a  child  of  three 
yeai'S. 

Later,  the  ammonium  salts,  especially  the  carbonate,  are 
more  efficacious.  From  i  to  2  grains  of  the  latter  may  be 
given  every  three  or  four  hours  to  a  child  of  two  years. 
Ammonium  iodid  is  also  useful,  and  may  be  employed  as  an 
adjuvant,  as  in  the  following  formula : 

R.    Ammonii  carbonatis gr.  xlviij 

Ammonii  iodidi gr.  xxiv 

Syrupi  tolutani 

Syrupi  acacise aa  q.  s.  ad  f^iij. — M. 

SiG. — Teaspoonful  every  two  or  three  hours  for  a  child  of  three 
years-. 

When  the  child  is  unable  to  expel  the  mucus  and  the 
breathing  becomes  much  oppressed,  an  emetic  (ipecac  or 
alum)  may  prove  of  great  service.  Inhalations  of  oxygen 
sometimes  make  breathing  easier.  Strychnin  is  also  of 
benefit  at  this  time  in  combating  respiratory  failure. 

If  symptoms  of  cardiac  failure  are  pronounced,  digitalis 
must  be  given  in  addition  to  alcohol  and  strychnin.  Ex- 
treme restlessness  and  insomnia  will  sometimes  require  the 
use  of  the  bromids  or  some  other  mild  sedative. 

Except  at  the  onset,  when  they  may  be  necessary  to  re- 
lieve pleuritic  pain  and  to  control  harassing  cough,  opiates 
should  not  be  used. 

Convalescence  must  be  guarded.     Tonics  like  cod-liver 


CHRONIC  INTERSTITIAL   PNEUMONIA.  255 

oil,   iron,  and  hypophosphites   are  useful   restoratives.      A 
change  of  air  is  desirable  in  protracted  cases. 

CHRONIC  INTERSTITIAL  PNEUMONIA* 

(Cirrhosis  of  the  Lung;  Chronic  Pneumonia;  Pulmonary  Indu- 
ration.) 

Definition. — A  chronic  disease  of  the  lung,  character- 
ized by  an  overgrowth  of  fibrous  tissue. 

Htiology. — It  is  a  rare  sequel  of  croupous  or  catarrhal 
pneumonia.  It  may  be  excited  by  the  constant  inhalation 
of  irritating  dusts,  as  stone-dust  (chalicosis),  coal-dust  (an- 
thracosis),  or  metal-dust  (siderosis).  It  may  result  from 
syphilis.  It  is  occasionally  secondary  to  chronic  pleurisy. 
It  is  an  invariable  accompaniment  of  chronic  phthisis. 

Pathology. — When  the  thorax  is  opened,  the  lung  is 
found  retracted  and  the  heart  displaced.  The  organ  is 
toug-h,  firm,  and  more  or  less  airless.  Section  shows  an 
overgrowth  of  fibrous  tissue,  and  usually  inflammation  and 
considerable  dilatation  of  the  bronchi. 

Symptoms. — The  chief  symptoms  are  dyspnea  on  exer- 
tion and  cough.  The  latter  may  be  dry,  but  it  is  usually 
associated  with  more  or  less  mucopurulent  sputum.  There 
is  no  fever,  and  the  general  health  may  be  well  preserved  for 
many  years. 

Physical  Signs. — Inspection  reveals  retraction  of  the 
affected  side  and  displacement  of  the  apex-beat. 

Percussion  may  yield  dulness.  Over  saccular  dilatations 
of  the  bronchi  there  may  be  a  tympanitic  note. 

Auscultation. — The  vocal  resonance  is  increased,  and  the 
breathing  is  often  bronchial  or  cavernous. 

Diagnosis. — Fibroid  Phthisis. — This  is  often  bilateral  ; 
fever  is  a  frequent  accompaniment,  and  tubercle  bacilli  are 
present  in  the  sputa. 

Prognosis. — The  disease  is  incurable.  Its  course,  how- 
ever, is  extremely  chronic. 

Treatment. — This  is  largely  hygienic,  and  coincides 
with  that  laid  down  for  tuberculosis.  Stimulant  expecto- 
rants are  useful  when  bronchitis  or  bronchiectasis  is  a 
prominent  feature. 


256        DISEASES    OF   THE   RESPIRATORY  SYSTEM. 

ABSCESS  OF  THE  LUNG. 

l^tiology. — (i)  It  is  a  rare  sequel  of  croupous  or 
catarrhal  pneumonia.  (2)  It  is  a  frequent  accompaniment 
of  tuberculosis.  (3)  It  may  be  excited  by  the  inhalation  of 
foreign  bodies.  (4)  It  may  result  from  the  extension  of  a 
suppurative  inflammation  in  some  neighboring  part,  such  as 
the  pleura  or  liver.  (5)  Multiple  abscesses  of  embolic  origin 
are  of  common  occurrence  in  pyemia. 

Symptoms. — High  and  irregular  fever,  rigors,  sweats, 
pallor,  and  leukocytosis  indicate  suppuration.  Dyspnea, 
cough,  and  purulent,  offenisive  sputa  containing  shreds  of 
lung  tissue  are  the  pulmonary  symptoms.  Physical  exami- 
nation may  reveal  bubbling  rales,  and,  later,  cavernous 
breathing  and  pectoriloquy.  Multiple  embolic  abscesses 
are  rarely  recognized  during  life. 

Prognosis. — Many  cases  following  pneumonia  and  the 
rupture  of  external  abscesses  into  the  lung  recover.  Em- 
bolic abscess  always  prove  fatal. 

Treatment. — Nutritious  food  and  quinin,  strychnin,  and 
alcoholic  stimulants  will  be  required  to  support  the  system. 
Single  abscesses,  when  they  can  be  localized,  should  be 
opened  and  drained. 

GANGRENE  OF  THE  LUNG. 

etiology. — Gangrene  of  the  lung  is  not  a  primary  con- 
dition, but  is  secondary  to  inflammation  or  necrosis  of  the 
lung  tissue.  It  is  excited  by  the  entrance  of  bacteria  of 
putrefaction,  but  unless  the  system  is  considerably  reduced 
in  vitality,  the  tissues,  even  though  diseased,  show  wonder- 
ful resistance  and  escape  putrefaction. 

Pneumonia,  especially  aspiration-pneumonia,  phthisis, 
pressure  of  morbid  growths,  bronchiectasis,  abscess,  and 
hemorrhagic  infarction  following  embolism  of  the  pulmonary 
artery  are  the  predisposing  pulmonary  conditions ;  Bright's 
disease,  alcoholism,  the  infectious  fevers,  and  particularly 
diabetes,  by  lowering  vitality,  render  the  lung  more  liable 
to  be  attacked. 

Pathology. — The   process    may   be    circumscribed    or 


PULMONARY  TUBERCULOSIS.  257 

diffuse.  The  affected  part  is  converted  into  a  greenish- 
black,  soft  mass  having  an  extremely  fetid  odor.  When 
the  softened  material  has  been  expectorated,  there  is  left 
behind  a  cavity  with  ragged  walls,  containing  a  foul-smell- 
ing liquid.  The  tissues  around  the  cavity  are  inflamed  and 
edematous. 

Symptoms. — Persistent  cough,  irregular  fever,  and  ema- 
ciation are  usually  present.  Hemoptysis  is  a  frequent  oc- 
currence. The  expectoration  is  characteristic  ;  it  is  profuse, 
and  has  a  penetrating,  offensive  odor.  When  allowed  to 
stand  in  a  glass  vessel,  it  separates  into  three  layers  :  a  frothy 
layer  on  top,  a  translucent  serous  layer  in  the  middle,  through 
which  hang  strings  of  pus,  and  at  the  bottom  a  layer  of 
reddish-green  purulent  material.  Altered  blood  may  give 
it  the  appearance  of  prune-juice.  Microscopically  it  con- 
tains shreds  of  tissue,  crystals  of  fatty  acids,  crystals  of 
hematoidin,  and  numerous  pyogenic  bacteria. 

Physical  examination  may  reveal  bubbling  rales,  and  later 
cavernous  breathing,  pectoriloquy,  and  localized  tympany 
on  percussion.  Physical  signs  of  pyopneumothorax  may 
supervene  from  perforation  into  the  pleura. 

Prognosis. — Grave,  but  not  hopeless.  Quite  a  number 
of  cures  have  been  recorded.  Death  may  result  from  ex- 
haustion, hemorrhage,  or  cerebral  abscess  the  result  of 
embolism. 

Treatment. — Nutritious  food  and  strychnin,  quinin,  and 
alcohol  are  required  to  support  the  system.  Inhalations  of 
creasote  or  of  formalin  (2  per  cent,  gradually  increased  to  5 
per  cent.)  may  be  employed  to  lessen  the  fetor  of  the 
breath.  Surgical  interference  is  indicated  when  the  gan- 
grenous process  can  be  localized  and  is  not  a  complication 
of  an  incurable  disease. 

PULMONARY   TUBERCULOSIS* 

(Phthisis ;  Pulmonary  Consumption.) 

Definition. — A  specific  inflammatory  disease  of  the  lungs 
caused  by  the  Bacillus  tuberculosis ;  characterized  anatomi- 
17 


258         DISEASES   OF  THE  RESPIRATORY  SYSTEM. 

cally  by  a  cellular  infiltration  that  subsequently  caseates, 
softens,  and  leads  to  ulceration  of  the  lung  tissue  ;  and  mani- 
fested clinically  by  wasting,  exhaustion,  fever,  and  cough. 

etiology. — It  most  commonly  develops  between  the 
ages  of  fifteen  and  forty,  (i)  An  inherited  susceptibility  to 
infection ;  (2)  residence  in  low,  damp,  and  badly  drained 
localities  ;  (3)  occupations  that  necessitate  the  breathing  of 
impure  air  and  irritating  dusts ;  (4)  catarrhal  affections  of 
the  respiratory  tract;  (5)  chronic  alcoholism  ;  (6)  certain 
general  diseases,  such  as  whooping-cough,  measles,  diabetes, 
cirrhosis  of  the  liver,  and  nephritis  are  important  predispos- 
ing factors. 

The  exciting  cause  is  the  Bacillus  tuberculosis.  Infection 
takes  place — (i)  By  the  inhalation  of  air  laden  with  the  dust 
of  dried  tuberculous  expectoration  ;  (2)  by  the  ingestion  of 
tuberculous  milk  or  meat ;  (3)  by  the  direct  inoculation  of 
wounds  (rare) ;  and  (4)  by  direct  parental  transmission  (very 
rare). 

Pathologfy. — The  Bacillus  tuberculosis  is  a  very  minute 
rod,  about  one-fourth  or  one-half  as  long  as  the  diameter  of 
a  red  blood-corpuscle,  and  often  slightly  bent  and  beaded. 
Its  detection  depends  on  the  power  of  the  stained  bacillus 
to  resist  the  decolorizing  effects  of  acids.     (See  p.  204.) 

The  lodgment  of  the  bacilli  in  the  terminal  bronchioles 
or  peribronchial  tissues  excites  a  proliferation  of  the  fixed 
connective-tissue  cells.  The  new  cells,  from  their  resem- 
blance to  epithelial  cells,  are  known  as  epithelioid  cells.  They 
have  a  relatively  large  amount  of  protoplasm  and  a  rather 
faintly  staining  nucleus.  Giant-cells  are  sometimes  formed 
by  the  fusion  or  overgrowth  of  the  epithelioid  cells.  In  con- 
sequence of  the  local  irritation  the  cellular  proliferation  is 
soon  surrounded  by  a  wall  of  leukocytes,  the  whole  forming 
a  gray,  translucent  mass — the  gray  tubercle  of  Laennec. 
In  a  short  time  the  bacilli  excite  a  coagulation-necrosis  that 
starts  in  the  center,  spreads  to  the  periphery,  and  converts 
the  tubercle  into  a  yellow,  cheesy  mass — the  yellow  tubercle 
of  Laennec.  The  degenerated  tubercles  fuse  and  form  the 
uniform  cheesy  masses  so  commonly  observed  at  the  autopsy. 
At  this  stage  one  of  two  things  may  occur :  the  mass  may 


PULMONARY  TUBERCULOSIS.  259 

soften,  break  into  a  bronchial  tube,  and  leave  behind  a  cavity 
with  ulcerating  walls,  or  it  may  become  encapsulated  by  an 
overgrowth  of  connective  tissue  and  subsequently  calcified. 
In  addition  to  the  specific  process  other  secondary  changes 
are  noted.  The  lung  tissue  in  the  neighborhood  of  the 
tuberculous  deposits  is  often  the  seat  of  a  true  pneumonic 
inflammation ;  the  connective  tissue  is  always  more  or  less 
proliferated ;  the  bronchial  tubes  are  inflamed ;  and  the 
pleural  surfaces  over  the  affected  areas  are  nearly  always 
adherent. 

Chronic  ulcerative  phthisis  usually  begins  at  the  apices. 

Acute  phthisis  has  been  termed  phthisis  florida,  cheesy 
pneumonia,  and  chronic  catarrhal pnewnonia,  but  the  process 
is  invariably  tuberculous.  From  extreme  vulnerability  of 
the  tissues  a  lobe  or  whole  lung,  or  even  both  lungs,  is 
rapidly  infiltrated,  and  death  results  in  from  a  i^v^  weeks  to 
a  few  months. 

In  some  cases  the  lung  is  solidified  by  a  dense,  yellow- 
ish-gray infiltration  composed  of  closely  aggregated  tuber- 
cles ;  in  others  the  consolidation  appears  in  more  or  less 
discrete  patches  that  have  had  their  origin  in  the  smaller 
bronchial  tubes  ;  in  a  third  form  one  or  both  lungs  are 
studded  with  discrete  tubercles,  many  of  which  are  still  gray 
and  translucent. 

In  fibroid  phthisis  the  tissues  are  more  resistant,  and  in 
consequence  the  process  is  limited  by  an  overgrowth  of  con- 
nective tissue  that  forms  dense  bands  around  the  tuberculous 
foci.     This  form  lasts  many  years. 

Chronic  Ulcerative  Phthisis.—  Symptoms. — The  onset 
is  usually  insidious  and  marked  by  pallor,  gastric  dis- 
turbance, loss  of  flesh  and  strength,  and  by  a  dry,  hacking 
cough  that  is  noted  especially  in  the  morning.  From  some 
undue  exposure  the  cough  is  often  aggravated,  and  to  this 
obstinate  "  cold  "  the  disease  is  usually  attributed.  In  some 
cases  the  symptoms  appear  abruptly  with  hemorrhage  or  an 
acute  pleurisy. 

Slight  fever  and  acceleration  of  the  pulse  are  early  symp- 
toms of  great  diagnostic  import.     The  temperature  is  marked 


26o        DISEASES    OF   THE   RESPIRATORY  SYSTEM. 

by  an  evening  exacerbation,  during  which  the  face  is  flushed, 
the  eyes  are  bright,  and  the  mind  animated.  As  the  disease 
advances  the  cough  becomes  troublesome  and  the  expec- 
toration more  abundant.  In  well-developed  cases  the  ex- 
pectoration is  greenish  in  color,  is  in  coin-shaped  plugs 
(nummular),  is  heavy  and  sinks  in  water,  is  often  blood- 
streaked,  and  on  microscopic  examination  is  found  to  con- 
tain bacilli  and  fibers  of  elastic  tissue. 

Phthisis  is  in  itself  not  a  painful  disease,  but  the  associated 
dry  pleurisy  often  causes  much  suffering.  Hemoptysis  occurs 
at  all  stages,  but  the  profuse  hemorrhages  occur  late.  The 
blood  is  bright  red  in  color,  frothy,  and  mixed  with  mucus. 
Dyspnea  is  rare  until  the  disease  is  far  advanced.  Profuse 
sweating  during  sleep  is  a  troublesome  feature  of  advanced 
phthisis. 

The  final  stage  is  characterized  by  extreme  emaciation, 
weakness,  pallor,  high  remittent  or  intermittent  fever,  and 
edema  of  the  feet.  The  mind  is  usually  clear  and  pecuHarly 
hopeful  to  the  end.  The  average  duration  is  about  two 
years. 

Physical  Examination. — The  chest  may  be  well  formed. 
Often,  however,  it  is  long  and  flat,  with  hollow  supracla- 
vicular and  infraclavicular  spaces,  prominent  scapulae,  and 
oblique  ribs.  When  the  disease  is  well  advanced,  there 
may  be  retraction  with  diminished  expansion  over  one  apex. 

Palpation. — This  reveals  imperfect  expansion  and  ex- 
aggerated vocal  fremitus. 

Percussion. — Dulness  can  be  detected  at  an  early  period 
of  the  disease.  It  may  be  obtained  first  above  or  below  the 
clavicles,  in  the  supraspinous  fossae,  between  the  scapulae,  or 
in  front,  near  the  sternal  border. 

A  cavity  may  yield  tympany  or  a  cracked-pot  note.  The 
latter  is  best  obtained  with  quick,  light  percussion  strokes, 
when  the  patient's  mouth  is  open. 

Auscultation. — In  the  earliest  stage  respiration  may  be 
inaudible  over  the  affected  area.  Later  the  breathing  is 
harsh  and  the  expiration  is  prolonged  (bronchial).  The  vocal 
resonance  is  increased.  Crackling  rales  are  usually  audible, 
and  are   produced   by  hquid    in   the   small   tubes.     If  not 


PULMONARY  TUBERCULOSIS,  26 1 

present,  coughing  will  usually  develop  them.  Auscultation 
over  cavities  may  detect  cavernous  or  amphoric  breathing, 
bronchophony  or  pectoriloquy,  and  large  gurgling  rales. 

Anomalous  Physical  Signs. — The  vocal  fremitus  is  dimin- 
ished when  there  is  much  pleural  thickening.  Normal 
resonance  or  hyperresonance  may  replace  dulness  when 
there  is  much  emphysema  between  small  tuberculous  foci. 
Weak  breathing  may  replace  bronchial  or  cavernous  when 
the  tubes  or  cavity  are  filled  with  mucopus.  The  signs  of 
cavity  are  sometimes  produced  by  consolidation  in  the 
neighborhood  of  a  large  bronchus. 

Acute  Phthisis. — Clinically  this  form  resembles  pneu- 
monia, and  is  marked  by  a  chill,  high  fever,  rapid  pulse, 
dyspnea,  sputum  at  first  rusty  and  then  purulent,  flushed 
face,  profuse  sweats,  and  the  signs  of  consolidation.  Instead 
of  ending  by  crisis  at  the  eighth  or  ninth  day,  as  in  ordinary 
pneumonia,  the  symptoms  gradually  grow  worse,  signs  of 
softening  develop,  bacilli  and  elastic  fibers  appear  in  the 
sputum,  emaciation  and  anemia  become  pronounced,  and 
death  results  in  from  a  few  weeks  to  a  few  months. 

Fibroid  Phthisis. — This  is  a  disease  of  long  duration. 
It  is  characterized  by  very  gradual  loss  of  flesh  and  strength 
and  by  an  abundant  mucopurulent  expectoration,  which  is 
at  times  fetid  from  being  retained  in  dilated  bronchi.  Dysp- 
nea, sweating,  and  fever  are  slight.  There  is  very  marked 
retraction  on  the  affected  side  from  the  shrinking  of  the 
fibrous  tissue ;  with  this  exception  the  physical  signs  are 
similar  to  those  of  ulcerative  phthisis. 

Complications  of  Phthisis. — The  chief  are  :  hemop- 
tysis ;  catarrhal  pneumonia;  pleurisy;  pneumothorax;  stom- 
atitis ;  gastric  catarrh ;  diarrhea ;  amyloid  degeneration  of 
the  viscera ;  fistula  in  ano  (tuberculous) ;  and  secondary 
tuberculosis  of  other  organs,  especially  of  the  larynx,  cere- 
bral meninges,  intestines,  peritoneum,  or  kidneys. 

Diagnosis. — The  irregular  fever,  cough,  pallor,  emacia- 
tion, hemoptysis,  night-sweats,  signs  of  consoHdation,  and 


262        DISEASES   OF  THE  RESPIRATORY  SYSTEM. 

the  presence  of  bacilli  and  elastic  fibers  in  the  sputa  are  the 
diagnostic  phenomena. 

Prognosis. — In  acute  phthisis  the  outlook  is-  wholly 
unfavorable.  In  chronic  phthisis  the  prognosis  is  dependent 
upon  the  stage  of  the  disease,  the  constitutional  vigor  of  the 
subject,  and  the  hygienic  conditions  under  which  he  is 
obliged  to  live.  The  accidental  discovery  of  calcified  tuber- 
cles at  autopsies  furnishes  abundant  proof  of  the  curability 
of  the  disease.  The  mortality  is  very  high  in  young  sub- 
jects (fifteen  to  twenty-five  years)  and  those  of  feeble  con- 
stitution. Unfavorable  prognostic  signs  are  a  persistent 
high  temperature,  rapid  pulse  (no  to  120),  involvement 
of  both  lungs,  continued  indigestion,  progressive  loss  of 
flesh,  and  the  development  of  tuberculous  lesions  in  other 
organs. 

Treatment. — Prophylaxis. — Tuberculous  patients  should 
be  taught  to  expectorate  only  into  proper  receptacles  con- 
taining a  disinfectant  solution  (5  per  cent,  carbolic  acid)  or 
into  moistened  rags  or  paper  napkins  that  should  be  burned 
before  the  sputum  becomes  dry.  They  should  sleep  alone. 
Their  rooms  should  be  sunny,  well  ventilated,  and  kept 
scrupulously  clean. 

Much  can  be  done  by  the  State  to  limit  the  dissemination 
of  the  disease.  Laws  should  be  enacted  providing  for  the 
systematic  inspection,  by  skilled  veterinarians,  of  all  dairies 
and  slaughter-houses  with  the  view  of  declaring  unmarket- 
able the  milk  and  meat  of  tuberculous  animals. 

Compulsory  registration  of  phthisical  patients  is  desirable. 
Spitting  upon  sidewalks  and  the  floors  of  public  buildings 
and  conveyances  should  be  made  a  penal  offense.  Finally, 
the  State  should  provide  special  hospitals  for  the  indigent 
suffering  from  tuberculosis. 

Persons  with  a  predisposition  to  tuberculosis  can  do  much 
to  increase  their  powers  of  resistance  by  strict  attention  to 
hygiene.  Fresh  air  and  sunHght,  a  healthy  residence,  an 
outdoor  occupation,  the  wearing  of  warm  clothes,  with  flan- 
nel next  to  the  skin,  and  a  diet  of  wholesome  and  nutritious 
food,  temperate  living,  systematic  exercise,  and  daily  cold 
sponging,  followed  by  friction  of  the  skin,  are  the  factors  to 


PULMONARY  TUBERCULOSIS.  263 

be  relied  upon  in  attempting  to  overcome  individual  sus- 
ceptibility. 

Finally,  all  local  foci  of  tuberculosis,  such  as  frequently 
appear  in  the  cervical  lymph-glands,  joints,  and  bones,  should 
receive  immediate  attention. 

Sanatorium  treatment  undoubtedly  gives  the  patient  the 
best  chance  of  recovery.  In  such  institutions  the  patient 
spends  in  summer  not  less  than  nine  or  ten  hours,  and  in 
winter  not  less  than  from  six  to  nine  hours,  in  the  open  air. 
The  bedroom  windows  are  kept  open  both  winter  and  sum- 
mer. He  is  given  a  mixed  diet  of  wholesome  food,  and  en- 
couraged to  eat  as  heartily  as  his  digestive  capacity  will  permit. 
When  the  disease  is  active,  he  is  kept  at  absolute  rest.  For 
the  most  of  the  day  he  lies  on  a  bamboo  couch  in  the  open 
air,  warmth  being  maintained  by  abundant  covering  and, 
if  necessary,  by  a  hot  stone  at  the  feet.  In  quiescent  tuber- 
culosis moderate  exercise  is  recommended,  every  precaution 
being  taken,  however,  to  guard  against  fatigue.  To  secure 
lasting  improvement,  the  patient  should  remain  in  the  sana- 
torium at  least  six  months. 

Climatic  Treatment. — To  patients  to  whom  a  protracted 
stay  in  a  sanatorium  would  be  irksome  or  distasteful  a  change 
of  cHmate  offers  the  greatest  hope  of  cure.  As  a  rule,  a 
high  altitude  should  be  selected ;  the  atmosphere  should  be 
dry,  and  the  temperature  equable.  Personal  experience  must 
decide  the  question  of  temperature ;  generally  patients  who 
feel  better  in  summer  will  do  well  in  a  warm  climate,  and 
vice  versa.  The  physician  should  have  some  knowledge  of 
the  locality,  which  should  afford  ordinary  conveniences 
without  being  too  crowded  with  sufferers  similarly  afflicted. 

In  selected  cases  a  sea  voyage  is  often  very  useful.  Ac- 
cording to  Douglas  Powell,  it  is  most  suitable  to  patients  in 
the  early  stages,  who  have  been  previously  healthy,  who 
have  overworked  nervous  systems,  and  in  whom  the  disease 
is  more  or  less  quiescent. 

Treatment  at  Home. — This  should  be  made  to  imitate  as 
closely  as  circumstances  will  permit  that  which  is  followed 
in  the  sanatorium.  The  airiest  and  sunniest  room  should  be 
selected  for  the  patient.     So  long  as  he   has  fever  absolute 


264        DISEASES   OF   THE   RESPIRATORY  SYSTEM. 

rest  should  be  insisted  upon.  As  much  nourishing  food 
should  be  allowed  as  he  is  capable  of  digesting. 

Medicinal  Treatment. — When  well  tolerated  and  digested, 
cod-liver  oil  (i  to  4  fluidrams  thrice  daily)  is  of  service  in 
improving  the  general  nutrition.  Creasote  is  useful  when 
the  expectoration  is  free  and  purulent.  The  dose  should  be 
cautiously  increased  from  2  or  3  minims  to  1 5  or  20  minims, 
three  times  a  day.  Alcohol  is  useful  in  some  cases.  Malt 
liquors  and  wines  are  usually  the  best  preparations.  Tonics 
— arsenic,  iron,  hypophosphites — are  often  serviceable.  lodin 
appears  to  be  effective  in  chronic  cases.  A  small  amount  of 
an  ointment  of  europhen  (10  per  cent.),  a  compound  contain- 
ing much  loosely  combined  iodin,  may  be  rubbed  into  the 
chest  twice  daily.  Counterirritation  by  means  of  small 
blisters  is  also  efficacious  in  chronic  forms. 

Symptomatic  Treatment. —  Cough. — In  many  cases  cough 
is  indispensable  and  is  best 'treated  by  promoting  expectora- 
tion. For  this  purpose  creasote,  guaiacol  carbonate,  tere- 
bene,  oil  of  eucalyptus,  and  myrtol  are  reliable  remedies. 
Inhalations  of  ipecac,  creasote,  compound  tincture  of  ben- 
zoin, or  terebene  are  often  very  effective.  Local  blistering 
is  also  of  service.  When  the  cough  is  very  severe,  seda- 
tives must  be  given.  Of  these,  the  least  objectionable  are 
codein,  heroin,  hydrocyanic  acid,  and  spirit  of  chloroform. 
Such  combinations  as  the  following  will  be  found  useful : 

JB^.    Codein8e  sulphatis gr.  vj-viij 

Spiritus  chloroformi fpjj 

Glycerin f^j 

Sued  limonis f^ss 

Aquae q.  s.  ad  f^iij.— M. 

SiG. — A  teaspoonful  as  occasion  demands. 

R .    Codeinse  sulphatis gi*-  iv 

Acidi  hydrocyanici  diluti TTt  xxxij 

Syrupi  lolutani      q.  s.  ad  f^ij.— M. 

SiG. — A  teaspoonful  as  required. 

Night-szveats. — Sponging  the  body  at  bedtime  with  a  solu- 
tion of  alum  in  alcohol  and  water  or  dusting  it  with  a  powder 
of  tannoform  (i  part)  and  zinc  oxid  (3  parts)  is  sometimes 
very  effective.  The  most  reliable  internal  remedies  are 
atropin  (y^o  to  yfg-  grain),  picrotoxin  (^  to  ^  grain),  arc- 


PLEURISY.  265 

matic  sulphuric  acid  (5  to  10  drops),  and  camphoric  acid  (5 
to  10  grains). 

R.    Atropinae  sulphatis g^-  i- 

Acidi  sulphurici  aromatici fziij 

Aquae  menthae  piperitae q.  s.  f^iij. — M, 

SiG. — Teaspoonful  in  water  at  bedtime. 

Pyrexia. — In  many  cases  the  fever  yields  to  absolute  rest 
in  bed  or  in  a  reclining  chair,  combined  with  life  in  the  open 
air.  Cold  sponging  is  useful  when  the  temperature  is  high. 
In  obstinate  cases  the  administration  of  phenacetin  (3  to  5 
grains)  may  be  tried. 

Pleuritic  Pains. — Mild  attacks  generally  yield  to  sinapisms 
or  the  application  of  iodin.  Strapping  the  affected  side  also 
affords  relief.  Severe  pains  should  be  treated  by  the  appli- 
cation of  small  blisters  and  the  subcutaneous  administration 
of  morphin. 

Diarrhea. — Diarrhea,  the  result  of  indigestion,  usually 
yields  promptly  to  restriction  of  the  diet,  rest,  and  the  admin- 
istration of  a  mild  mercurial.  Persistent  diarrhea  will  demand 
the  use  of  bismuth  subnitrate  (20  to  30  grains)  combined 
with  opium  and  intestinal  antiseptics — salol,  bismuth-beta- 
naphthol,  or  creasote.  Combinations  of  tannigen  (5  to  15 
grains)  or  tannalbin  (5  to  15  grains)  with  bismuth  compounds 
are  also  useful : 

R.    Tannigen   .    .  ^j 

Bismuth-beta-naphthol ^^ij 

Codeinae  sulphatis gr.  v. — M. 

Fiant  chartulae  No.  xij. 

SiG. — One  every  four  hours. 

Hemoptysis  (see  p.  240). 


DISEASES   OF  THE  PLEURA. 
PLEURISY, 

(Pleuritis.) 

Definition. — Inflammation  of  the  pleura. 
Varieties. — According  to  cause,  it  may  be  divided  into 
primary  or  secondaiy  ;  according  to  extent,  into   unilateral. 


266        DISEASES   OF   THE   RESPIRATORY  SYSTEM. 

bilateral,  or  local ;  according  to  time,  into  acute  or  chronic ; 
and  according  to  the  exudation,  into  serofibrinous,  fibrinous, 
or  purulent. 

ifetiologfy. — Pleurisy  may  be  :  ( i)  Idiopathic,  arising  from 
exposure  to  cold  and  wet.  (2)  Traumatic.  (3)  Secondary  to 
inflammatory  diseases  of  adjacent  viscera,  as  pneumonia  and 
phthisis.  (4)  Secondary  to  some  general  morbid  process,  as 
rheumatism,  Bright's  disease,  and  the  infectious  fevers.  (5) 
Tuberculosis.     (6)  Cancerous  (rare). 

At  least  three-fourths  of  all  cases  of  serofibrinous  pleurisy 
are  tuberculous. 

Pathology. — In  the  early  stage  the  membrane  is  red, 
sticky,  lusterless,  and  covered  with  a  thin  film  of  lymph ;  \i 
the  process  now  ceases,  the  condition  is  termed  diy  pleurisy. 
If,  however,  the  inflammation  continues,  an  exudate  is  formed 
which  may  be  :  (i)  Serofibrinous  ;  (2)  fibrinous  ;  or  (3)  pur- 
ulent (empyema).  In  the  serofibrinous  form  there  is  little 
lymph,  the  exudate  being  mainly  composed  of  straw-colored 
serum  (a  few  ounces  to  several  pints)  which  in  favorable 
cases  is  gradually  absorbed.  In  large  effusions  the  adjacent 
organs  are  displaced  and  the  lungs  are  compressed.  In  the 
fibrinous  form  serum  is  scant  and  the  membrane  is  covered 
with  a  butter-like  exudate  that  subsequently  organizes  and 
unites  more  or  less  closely  the  pleural  surfaces,  causing 
chronic  pleural  thickening.  A  liquid  effusion,  which  is  cir- 
cumscribed and  confined  to  pockets  formed  by  adhesions,  is 
termed  sacculated  pleurisy. 

Puridejit pleuiHsy  is  always  the  result  of  micro-organismal 
infection.  Left  to  itself,  it  may  kill  by  sepsis,  it  may  become 
inspissated  and  encysted  (very  rare),  or  it  may  rupture 
spontaneously  into  the  lung  and  bronchi,  or  more  rarely 
through  the  chest-walls.  After  the  discharge  of  the  pus, 
the  pleural  surfaces  may  eventually  become  united  by  firm 
adhesions. 

Hemorrhagic  Pleurisy. — A  bloody  effusion  is  often  ob- 
served in  tuberculous  and  cancerous  pleurisies  and  in  pleurisy 
associated  with  scurvy,  grave  anemia,  and  other  cachectic 
states. 

Symptoms. — The  disease  usually  sets  in  with  a  sharp 


PLEURISY.  267 

stabbing  pain  in  the  side,  aggravated  by  deep  breathing. 
The  respirations  are  rapid  and  shallow. 

Fever  is  moderate  in  degree  (101°  to  103°  F.). 

There  is  a  slight  irritative  coiig/i,  but  no  expectoration. 
As  the  effusion  accumulates,  the  pain  diminishes,  but  dyspnea 
and  cyanosis  gradually  develop. 

In  some  cases  (latent  pleiiris)>)  the  disease  begins  in- 
sidiously, weakness  and  dyspnea  being  the  first  symptoms 
to  attract  attention. 

Physical  Signs. — Inspectio?i. — In  the  first  stage  there 
may  be  deficient  expansion  on  the  affected  side,  owing  to 
the  severe  pain.  After  the  development  of  a  liquid  effusion 
the  characteristic  features  are  immobility,  bulging  of  the  in- 
tercostal spaces,  and  displacement  of  the  apex-beat. 

Palpation  reveals  immobility  of  the  affected  side  and  ab- 
sence of  the  vocal  fremitus. 

Percussion  yields  marked  dulness  or  flatness  and  a  sensa- 
tion of  increased  resistance.  The  upper  line  of  dulness  is 
not  horizontal,  but  is  curved  and  rises  higher  posteriorly. 
In  moderate  effusions  the  level  of  dulness  often  changes  with 
the  position  of  the  patient.  Above  the  effusion  percussion 
gives  a  tympanitic  note  (Skoda's  resonance).  In  left-sided 
effusions  Traube's  semilunar  space  is  obliterated. 

Auscultation. — In  the  early  stage  this  detects  a  to-and-fro 
friction-sound  of  respiratory  rhythm.  After  the  development 
of  the  effusion  the  respiratory  sounds  are  weak  and  distant. 
Occasionally  they  have  a  tubular  quality,  especially  near  the 
margins  of  the  liquid.  Vocal  resonance  is  usually  dimin- 
ished or  absent,  but  occasionally,  when  the  effusion  is  mod- 
erate, egophony  may  be  heard.  The  friction-sound  may 
again  be  audible  when  the  fluid  disappears. 

Mensuration  shows  an  increase  in  the  size  (|  to  i  inch)  of 
the  affected  side. 

Diagnosis. — Croupous  Pneumonia. — The  severe  chill, 
rusty  expectoration,  high  fever,  the  fine  inspiratory  rales, 
dulness  not  changing  with  the  patient's  posture,  increased 
vocal  fremitus,  increased  vocal  resonance,  loud  bronchial 
breathing,  and  the  absence  of  bulging  and  of  displaced 
apex-beat  will  serve  to  distinguish  pneumonia  from  pleurisy. 


268        DISEASES   OE  THE  RESPIRATORY  SYSTEM. 

Pleurodynia  (Rheumatism  of  the  Intercostal  Muscles). — In 
this  affection  the  pain  and  tenderness  are  diffuse ;  moreover, 
fever,  friction-sounds,  and  signs  of  effusion  are  absent. 

Diaphragmatic  Pleurisy. — This  may  present  the  following 
symptoms  :  Intense  pain  under  the  margin  of  the  ribs,  with 
tenderness  on  pressure;  thoracic  breathing;  tenderness  over 
the  phrenic  nerve,  which  is  accessible  between  the  two  roots 
of  the  sternocleidomastoid  at  the  base  of  the  neck ;  hiccup ; 
and  severe  dyspnea.     The  physical  signs  are  not  marked. 

Pericarditis  with  Effusion. — In  this  condition  the  percussion- 
dulness  has  a  characteristic  shape,  the  sounds  of  the  heart 
are  distant  and  muffled,  and  there  is  greater  embarrassment 
of  the  circulation. 

Hydrothorax. — In  this  condition  pain,  and  fever  are  absent. 
There  is  often  a  history  of  cardiac  or  renal  disease,  and  the 
fluid  on  aspiration  is  found  to  contain  less  than  3  per  cent, 
of  albumin  and  to  have  a  specific  gravity  below  10 15. 

Pyothorax. — This  may  be  recognized  by  the  general 
symptoms  of  sepsis — persistent  irregular  fever,  increasing 
pallor,  profuse  sweats,  chills,  and  leukocytosis.  In  doubtful 
cases  it  will  be  necessary  to  aspirate. 

Prognosis. — In  simple  serofibrinous  pleurisy  the  prog- 
nosis is  guardedly  favorable.  Fever  usually  subsides  in  from 
a  week  to  ten  days,  and  absorption  of  the  fluid  in  most  cases 
is  complete  in  from  four  to  six  weeks.  Sudden  death  occa- 
sionally occurs  when  the  fluid  is  excessive.  In  about  one- 
third  of  the  cases  tuberculosis  sooner  or  later  develops. 

Treatment. — The  patient  should  be  kept  in  bed  and  re- 
stricted to  a  liquid  diet.  Mercurial  or  saline  aperients  may 
be  prescribed  at  the  onset.  For  the  severe  pain  the  appHca- 
tion  of  a  blister  or  of  wet  or  dry  cups,  together  with  the 
administration  of  morphin,  will  be  found  effective.  Strapping 
the  affected  side  with  broad  strips  of  adhesive  plaster  is  also 
useful.  Acute  sthenic  cases  with  decided  fever  are  often 
favorably  influenced  by  the  administration  of  salicylates  (i 
to  I J  drams  of  the  sodium  or  ammonium  salt  a  day).  In 
asthenic  cases  salicylates  are  of  no  avail. 

Removal  of  Serous  Efftuion. — The  most  useful  measures 
for  promoting  absorption  are  the  application  of  iodin  or  of 


PLEURISY.  269 

flying  blisters,  and  the  administration  of  hydragogue  cathar- 
tics and  of  diuretics.  From  \  to  i  ounce  of  magnesium 
sulphate  may  be  given  in  as  little  water  as  possible  an  hour 
before  breakfast,  and  the  fluid  consumed  by  the  patient 
during  the  day  restricted  to  a  minimum.  The  most  service- 
able diuretics  are  digitalis,  caffein,  and  potassium  acetate. 
Potassium  iodid  (5  to  10  grains  thrice  daily)  is  also  em- 
ployed for  its  absorbent  effect.    Diaphoretics  are  of  little  vlaue. 

Paracentesis  is  demanded — (i)  When  the  efl'usion  is  con- 
siderable and  shows  no  signs  of  receding  after  the  lapse  of 
two  weeks  ;  (2)  when  there  is  sufficient  fluid  to  cause  severe 
dyspnea,  cyanosis,  persistent  cough,  or  failing  pulse ;  (3) 
when  the  fluid  reaches  the  level  of  the  second  rib  and  there 
is  marked  dislocation  of  the  neighboring  organs ;  (4)  when 
the  presence  of  pus  is  suspected. 

The  most  favorable  site  for  the  puncture  is  usually  in  the 
sixth  or  seventh  intercostal  space,  between  the  mid-axillary 
line  and  the  angle  of  the  scapula.  After  anesthetizing 
the  part,  the  needle  should  be  introduced  with  a  quick 
stroke  along  the  upper  margin  of  the  rib.  The  fluid  should 
be  removed  slowly,  and  under  no  circumstance  should  ex- 
treme efforts  be  made  to  obtain  the  largest  possible  amount. 
The  operation  should  be  terminated  at  once  if  incessant 
cough,  severe  pain,  dyspnea,  palpitation,  tendency  to  syn- 
cope, or  other  untoward  symptoms  appear. 

:^mpyema  (Pyothorax). — The  effusion  may  be  pri- 
marily purulent,  having  been  excited  by  pyogenic  micro- 
organisms, or  a  serofibrinous  effusion,  through  subsequent 
infection,  may  become  purulent.  Traumatism  or  the  rup- 
ture of  a  purulent  accumulation  into  the  pleural  sac  is  an 
occasional  cause.  It  frequently  follows  pneumonia,  particu- 
larly in  children,  in  whom  the  most  common  form  of  pleurisy 
is  empyema.  It  is  often  secondary  to  tuberculosis  or  one 
of  the  infectious  fevers. 

The  organisms  most  frequently  present  are  the  pneumo- 
coccus,  staphylococcus,  streptococcus,  tubercle  bacillus,  and 
typhoid  bacillus. 

Symptoms. — The  physical  signs  and  symptoms  are  simi- 
lar to   those   observed  in   serofibrinous    pleurisy.      Pus   is 


2/0        DISEASES   OF  THE   RESPIRATORY  SYSTEM. 

indicated  by  septic  phenomena — high  and  irregular  fever, 
sweats,  chills,  pallor,  and  leukocytosis  ;  by  the  results  of 
aspiration  ;  and  sometimes  by  edema  of  the  chest-walls.  In 
pulsating  pleurisy  the  effusion  is  almost  always  purulent. 

Prognosis. — Grave,  though  recovery  frequently  occurs. 
The  most  favorable  cases  are  those  following  pneumonia. 

Treatment. — This  consists  in  free  incision  and  thorough 
drainage.  Irrigation  is  unnecessary  unless  the  fluid  is  putrid. 
In  long-standing  cases  the  excision  of  several  ribs  (Estland- 
er's  operation)  facilitates  retraction  and  the  obliteration  of 
the  pleural  sac,  which  is  essential  to  a  cure. 

HYDROTHORAX*  . 

Definition. — A  serous  exudation  of  non-inflammatory 
origin  in  the  pleural  cavity. 

il^tiology. — It  is  always  secondary.  It  may  result  from 
one  of  the  causes  of  general  edema — heart  disease,  nephritis, 
emphysema,  or  anemia ;  it  may  be  due  to  pressure  upon  the 
veins  by  a  tumor,  aneurysm,  or  a  dilated  right  auricle  from 
mitral  disease.  It  is  usually  bilateral,  but  when  caused  by 
pressure  or  mitral  lesions,  it  is  frequently  unilateral. 

SyniptOttlS. — It  gives  rise  to  dyspnea,  cyanosis,  and 
the  physical  signs  of  a  pleural  effusion. 

Diagnosis. — This  is  based  upon  the  history,  the  absence 
of  pain  and  fever,  and  the  character  of  fluid  obtained  by 
aspiration  (see  p.  268). 

Treatment. — Remedies  should  be  directed  to  primary 
disease.  If  hydragogue  cathartics  and  diuretics  fail  to 
afford  relief  and  the  dyspnea  becomes  urgent,  aspiration 
must  be  practised. 

PNEUMOTHORAX. 

Definition. — Air  in  the  pleural  cavity. 

etiology.— About  90  per  cent,  of  the  cases  result  from 
the  rupture  of  a  tuberculous  cavity  into  the  pleura.  Rup- 
ture of  the  lung  from  abscess,  gangrene,  or  emphysema  is 
a  comparatively  rare  cause.     It  may  occur  after  the  spon- 


PNEUMOTHORAX,  2/1 

taneous  rupture  into  the  lung  of  an  empyema.  It  is  occa- 
sionally due  to  penetrating  wounds  of  the  chest. 

Path.olog'y. — The  adjacent  viscera  are  often  much  dis- 
placed and  the  lung  is  compressed.  Even  when  air  alone 
has  escaped  into  the  pleural  sac,  an  effusion  soon  forms,  so 
that  pneuinohydrothorax  or  pneinnopyotJwrax  is  an  almost 
inevitable  result. 

Symptoms. — The  onset  is  usually  marked  by  sharp 
pain,  severe  dyspnea,  cyanosis,  cough,  and  the  symptoms 
of  shock — subnormal  temperature,  a  weak,  rapid  pulse,  cold 
extremities,  and  pinched  features. 

Physical  Signs. — Inspection  may  reveal  distention  of 
the  affected  side,  immobility,  and  marked  displacement  of 
the  apex-beat. 

Palpation. — Vocal  fremitus  is  diminished. 

Pei'cussion. — Over  the  air  there  is  tympany.  At  the  base 
there  may  be  flatness,  changing  with  the  posture  of  the 
patient. 

Auscultation. — The  respiratory  murmur  and  vocal  reso- 
nance are  usually  absent,  but  when  the  opening  in  the  lung 
remains  patulous,  amphoric  breathing  may  be  detected. 
Metallic  tinkling  is  often  heard.  When  a  silver  coin  is 
placed  on  the  affected  side  and  is  struck  with  another,  the 
auscultator  may  detect  a  clear  metallic  sound  (bell-tympany). 
When  fluid  is  present,  shaking  the  patient  elicits  a  splashing 
sound  (Hippocratic  succussion). 

Diagnosis. — A  Large  Phthisical  Cavity. — This  is  usually 
located  near  the  apex  instead  of  the  base ;  the  surface  is 
sunken,  not  prominent;  the  heart  is  not  displaced;  succus- 
sion-splash  and  bell-tympany  are  rarely  obtainable. 

Dilated  Stomach. — This  may  give  a  tympanitic  note  over 
the  left  pulmonary  base,  and  may  simulate  a  pneumothorax; 
but  the  tympanitic  note  is  continued  down  into  the  abdomen, 
and  the  swallowing  of  liquid  is  distinctly  audible  over  the 
base  of  the  chest. 

Prognosis. — This  depends  on  the  cause.  In  tuberculous 
subjects  it  almost  always  proves  fatal  in  from  a  few  days  to 
a  few  months.  In  empyemic  and  traumatic  cases  the  out- 
look is  distinctly  more  favorable. 


2/2        DISEASES   OF  THE  RESPIRATORY  SYSTEM. 

Treatment. — In  tuberculous  cases  the  indications  are 
to  relieve  distress  by  morphin  and  to  combat  collapse  by 
such  stimulants  as  ether,  ammonia,  camphor,  alcohol,  and 
strychnin.  Aspiration  occasionally  affords  temporary  re- 
lief. In  non-tuberculous  cases  of  pneumopyothorax  opera- 
tive interference  is  generally  advisable. 

HEMOTHORAX. 

Definition. — Blood  in  the  pleural  cavity. 

!^tiology. — It  usually  results  from  wounds  of  the 
chest-wall,  fracture  of  the  ribs,  or  the  rupture  of  an  aneur- 
ysm. A  sanguineous  inflammatory  [hemorrhagic  pleurisy) 
exudate  frequently  occurs  in  cancerous  and  tuberculous 
pleurisy  and  in  simple  pleurisy  when  the  individual  is  pro- 
foundly anemic. 

Symptoms. — The  symptoms  and  physical  signs  are 
those  of  pleural  effusion.  ^ 


ACUTE  INFECTIOUS  DISEASES. 


FEVER* 

Fever  is  an  abnormal  condition,  characterized  by  elevated 
temperature,  quickened  respiration  and  circulation,  faulty 
secretions,  and  increased  tissue-waste.  It  is  dependent  upon 
a  perversion  of  the  physiologic  processes  whereby  the  gen- 
eration and  the  loss  of  heat  are  so  balanced  as  to  maintain  a 
uniform  normal  temperature. 

The  Detection  of  Fever. — There  is  only  one  reliable 
way  of  detecting  fever,  and  that  is  by  means  of  the  clinical 
thermometer.  The  instrument  may  be  placed  in  the  axilla, 
mouth,  rectum,  or  vagina. 

When  the  axilla  is  selected,  the  following  precautions 
must  be  observed  :  Wipe  off  the  perspiration  and  dry  the 
skin  ;  insert  the  bulb  of  the  instrument  deep  in  the  armpit, 
and  see  that  the  arm  is  kept  close  to  the  side.  The  ther- 
mometer should  be  kept  in  position  until  the  mercury  main- 
tains the  same  level  for  two  minutes ;  this  will  usually 
require  in  all  about  six  or  seven  minutes. 

When  the  mouth  is  selected,  the  bulb  should  be  placed 
under  the  tongue  and  the  lips  kept  closed.  Hot  or  cold 
drinks  recently  taken  mar  the  result.  For  obvious  reasons 
the  mouth  should  not  be  used  in  delirious  patients. 

The  rectum  may  be  selected  in  children.  The  rectal 
temperature  is  about  a  degree  higher  than  that  of  the 
axilla. 

Febrile  Stages. — The  course  of  all  fevers  is  marked  by, 
three  stages:  (i)  Invasion;  (2)  fastigium,  or  stadium;  (3) 
defervescence,  or  decline. 

Invasion. — During  this  period  the  temperature  gradually 
rises  until  it  reaches  its  maximum. 

18  ^  273 


274  ACUTE  INFECTIOUS  DISEASES. 

Fastigium. — In  this  period,  though  there  may  be  marked 
variations,  the  temperature  shows  a  tendency  to  touch  again 
and  again  its  highest  point. 

Defervescence. — In  this  period  the  temperature  gradually 
falls  until  it  reaches  the  norm. 

Terminations  of  Fever. — Fever  terminates  by  lysis  or 
crisis. 

Lysis. — The  temperature  falls  slowly  by  sHght  gradations 
until  it  reaches  the  norm. 

Crisis. — The  temperature  falls  suddenly — often  four  or 
five  degrees  in  twelve  or  twenty-four  hours. 

The  Degree  of  Pyrexia. — The  following  is  Wunder- 
lich's  classification  of  febrile  temperatures : 

1.  Subfebrile,  temperature  99.5°- 100.4°  F. 

2.  Slightly  febrile,  temperature  100.4°- 10 1.3°  F- 

3.  Moderately  febrile,  temperature  ioi.3°-i03.i°  F. 

4.  Decidedly  febrile,  temperature  103.1°- 104°  F. 

5.  Highly  febrile,  temperature  above  103.1°  F.  in  the 
morning  and  above  104.9°  F.  in  the  evening. 

6.  Hyperpyretic,  temperature  above  106°  F. 

Febrile  Remissions. — All  fevers  show  a  diurnal  varia- 
tion. The  maximum  is  usually  reached  at  about  6  p.  m. 
and  the  minimum  at  about  6  A.  m.  Occasionally  these  ex- 
tremes are  reversed  and  the  maximum  is  in  the  morning 
and  the  minimum  in  the  evening.  The  daily  difference 
amounts  to  about  1°  F. 

Types  of  Fever. — According  to  the  degree  of  the 
diurnal  variation  three  types  are  recognized : 

1.  Contimied  Fever. — The  diurnal  variation  is  slight — 
i°-i.5°  F.  Typhus  fever,  pneumonia,  and  scarlet  fever  are 
examples  of  continued  fevers. 

2.  Remittent  Fever. — The  diurnal  variation  is  marked,  but 
the  minimum  temperature  is  still  above  the  norm.  Typhoid 
fever,  remittent  fever,  and  septic  fever  are  examples  of  this 

3.  Intermittent  Fever. — The  diurnal  variation  is  marked, 
and  the  minimum  is  normal  or  subnormal.  The  following 
fevers  show  multiple  intermissions  : 

I.  Intermittent  malarial  fever. 


FEVER.  275 

2.  Relapsing  fever. 

3.  Septicemic  fever  (this  may  be  intermittent  or  remittent). 

4.  Hepatic  intermittent  fever  (see  p.  100). 

A  single  intermission  or  ^narked  remission  is  observed  in 
the  following  fevers  : 

Smallpox  (a  remission  occurs  about  the  third  day). 

Yellow  fever  (an  intermission  or  decided  remission  occurs 
about  the  third  or  fourth  day). 

-Measles  (a  distinct  remission  often  occurs  on  the  second 
or  third  day). 

Dengue  (an  intermission  occurs  about  the  third  or  fourth 
day  and  lasts  two  or  three  days). 

Causes  of  Pever. — The  chief  cause  is  disturbance  of 
the  heat-regulating  centers  by  toxic  substances  circulating 
in  the  blood.  These  substances  may  owe  their  origin  to  bac- 
terial invasion  (acute  infectious  diseases),  to  faulty  metabo- 
lism (acute  gout,  thermic  fever),  or  to  mechanical,  thermic,  or 
chemical  injury  of  the  tissues.  Occasionally,  as  in  hysteria, 
fever  appears  to  be  due  to  a  direct  disturbance  of  the  heat- 
regulating  centers. 

Symptoms  of  Fever. — The  temperature  is  elevated,  the 
pulse  is  accelerated,  the  respirations  are  increased,  the 
tongue  is  coated,  the  appetite  is  impaired,  the  secretions  of 
the  alimentary  canal  are  deficient,  and  the  urine  is  scanty, 
dark  colored,  and  of  high  specific  gravity.  Persistent  fever 
is  attended  with  great  wasting  of  the  body. 

The  pulse-temperature  ratio : 
A  temperature  of    98.4°  F.  corresponds  to  a  pulse  of  70. 

"    100°  F.  "  "         ''  80-90. 

"    102°  F.  "  "         "         loo-iio. 

"    104°  F.  "  "         ''         120-130 

Bffects  of  Fever  on  the  Tissues.— High  and  long- 
continued  fever  induces  certain  marked  changes  in  the 
tissues,  especially  cloudy  swelling,  fatty  degeneration,  and 
coagulation  necrosis. 

Treatment  of  Fever. — Febrile  patients  should  be  kept 
at  rest  in  a  cool,  well-ventilated  room.  The  diet  should 
be  liquid  or  semiliquid.  When  the  fever  is  moderate,  no 
special  treatment  is  required,  but  sponging  with  cool  water 


276  ACUTE   INFECTIOUS  DISEASES. 

or  with  alcohol  and  water  and  the  administration  of  such 
drugs  as  spirit  of  nitrous  ether,  solution  of  ammonium 
acetate,  or  neutral  mixture  afford  comfort.  High  fever  is 
best  controlled  by  cold  :  cold  sponging,  the  cold  pack,  or 
the  cold  bath. 

In  applying  the  cold  pack  the  bedding  is  first  protected 
by  water-proof  sheeting ;  the  patient  is  then  stripped  and 
enveloped  in  an  ordinary  sheet  wrung  out  of  water  at  a 
temperature  of  70^-60°  F.  The  pack  is  usually  continued 
for  from  ten  to  fifteen  minutes,  and  during  this  time  it  is 
necessary  to  sprinkle  the  sheet  at  frequent  intervals  with 
water  sufficiently  cool  to  maintain  a  uniform  temperature. 

The  Cold  Bath. — The  patient  is  wrapped  in  a  sheet  and 
then  placed  in  water  at  70°  F.  While  in  the  bath  an  ice-cap 
is  kept,  upon  the  head  and  the  trunk  and  Hmbs  are  vigor- 
ously rubbed,  so  as  to  bring  new  relays  of  blood  to  the 
surface.  A  stimulant  is  sometimes  given  before  the  bath  to 
lessen  the  shock.  At  the  end  of  fifteen  or  twenty  minutes 
the  patient  is  carried  back  to  bed  and  covered  with  a  dry 
sheet  and  a  light  blanket.  After  he  has  been  thoroughly 
dried  the  damp  coverings  are  removed  and  replaced  by  dry 
ones.  If  the  patient  be  delicate,  it  is  preferable  to  place  him 
in  a  bath  at  90°  F.  and  then  gradually  lower  the  tempera- 
ture of  the  water  to  70°  F. 

Drugs  may  also  be  used  to  lower  temperature,  but  the 
application  of  cold  is  generally  preferable.  Phenacetin,  anti- 
pyrin,  acetanilid,  and  quinin  are  the  antipyretic  drugs  most 
commonly  employed. 

Period  of  Incubation. — The  period  elapsing  between 
the  occurrence  of  the  infection  and  the  development  of 
symptoms. 

It  varies  considerably  in  the  same  disease,  being  more  or 
less  influenced  by  the  susceptibility  of  the  patient  and  the 
virulence  of  the  contagion.  The  average  period  of  incuba- 
tion in  the  various  fevers  is  as  follows : 

Typhoid  fever :  two  to  three  weeks. 
Typhus  fever :  a  few  days  to  two  weeks. 
Measles  :  ten  days  to  two  weeks. 


FEVER.  277 

Rotheln  or  rubella :  one  to  three  weeks. 
Scarlatina :  two  to  seven  days. 
Smallpox  :  ten  days  to  two  weeks. 
Erysipelas  :  three  to  seven  days. 
Diphtheria  :  two  to  seven  days. 
Varicella  :  fourteen  to  sixteen  days. 
Tetanus  :  a  few  days  to  three  weeks. 
Mumps  :  two  to  three  weeks. 
Yellow  fever:  from  three  to  four  days. 
Cholera :  two  to  five  days. 

The  date  at  which,  rashes  appear  in  the  various 
acute  infections : 

Typhoid  fever :  seventh  to  the  ninth  day. 
Typhus  fever :  fourth  or  fifth  day. 
Smallpox  :  third  or  fourth  day. 
Measles  :  third  or  fourth  day. 
Scarlatina  :  first  or  second  day. 
Rotheln  or  rubella  :  first  or  second  day. 
Varicella :  first  day. 

Protection  from  Future  Attacks. — Few  diseases 
confer  absolute  immunity  against  future  attacks,  but  the  fol- 
lowing are  fairly  protective  : 

Typhoid  fever :  relapses  are  common,  but  second  attacks 
are  infrequent. 

Typhus  fever  :  second  attacks  are  very  rare. 

Measles  :  second  attacks  are  uncommon. 

Rubella :  second  attacks  are  rare. 

Scarlet  fever :  second  attacks  are  rare. 

Smallpox  :  second  attacks  occasionally  occur. 

Mumps  :  second  attacks  are  rare. 

Varicella  :  second  attacks  are  uncommon. 

Yellow  fever  :  second  attacks  are  rare. 

The  following  specific  fevers  do  not  confer  immunity : 

Erysipelas.  Malarial  fever. 

Relapsing  fever.  Influenza. 

Diphtheria.  Croupous  pneumonia. 
Rheumatic  fever. 


278  ACUTE   INFECTIOUS  DISEASES. 

Termination  by  Crisis. — The  following  infectious  fevers 
are  apt  to  end  by  crisis  : 

Typhus  fever.  Measles. 

Pneumonia.  Relapsing  fever. 

Malarial  fever.  Erysipelas. 

Infections  in  which  jaundice  is  likely  to  occur : 

Yellow  fever. 

Relapsing  fever. 

Acute  yellow  atrophy  of  the  liver. 

Remittent  malarial  fever. 

SUBNORMAL  TEMPERATURE. 

Temperatures  below  97.5°  F.  may  be  considered  sub- 
normal.    They  are  observed  in  the  following  conditions  : 

1.  During  convalescence  from  certain  febrile  diseases. 
After  pneumonia  and  typhoid  fever  the  temperature  may 
remain  subnormal  for  several  days. 

2.  In  collapse  from  various  causes. 

3.  In  cholera.  In  this  disease  the  temperature  may  be 
very  low  (90°-85°  F.)  for  several  days. 

4.  In  certain  chronic  diseases,  especially  myxedema,  dia- 
betes, cancer,  chronic  cardiac,  cerebral,  and  spinal  diseases. 

SIMPLE  CONTINUED  FEVER. 
(Febricula ;  Ephemeral  Fever.) 

Definition. — An  acute  febrile  disease,  of  short  duration, 
without  definite  lesions  or  a  specific  etiology. 

l^tiology. — It  is  generally  met  with  in  young  and  sensi- 
tive individuals.  Exposure  to  the  sun,  prolonged  physical 
or  emotional  excitement,  and  errors  in  diet  seem  to  excite  it. 

Symptoms. — The  disease  usually  begins  abruptly  with 
chilliness,  headache,  malaise,  and  fever  which  soon  attains  a 
maximum  of  102°  or  103°  F.  The  face  is  flushed;  the 
pulse  is  full  and  rapid;  the  urine  is  scanty  and  high  colored; 
the  tongue  is  coated;  the  appetite  is  lost;  and  the  bowels 
are  constipated.  There  is  no  characteristic  eruption,  but 
herpes  is  frequently  observed  on  the  lips. 


TYPHOID   FEVER.  279 

The  disease  lasts  from  a  few  days  to  two  weeks,  and  may 
end  by  crisis  or  lysis. 

Diagnosis. — Care  must  be  taken  to  exclude  local  inflam- 
mations, such  as  gastritis,  tonsillitis,  and  pneumonia. 

Typhoid  Fever. — At  first  the  diagnosis  may  be  impossible, 
but  the  absence  of  diarrhea,  tympanites,  abdominal  tender- 
ness, splenic  enlargement,  Widal  reaction,  and  eruption  will 
soon  make  the  diagnosis  apparent. 

Remittent  Fever. — The  history,  the  splenic  enlargement, 
and  the  presence  of  hematozoa  in  the  blood  will  serve  to 
distinguish  this  disease  from  simple  continued  fever. 

Prognosis. — Favorable. 

Treatment. — The  patient  should  be  confined  to  bed  and 
placed  upon  a  liquid  or  semiliquid  diet.  Fractional  doses  of 
calomel  may  be  employed  to  relieve  constipation. 

The  fever  is  best  controlled  by  sponging  with  water  and 
alcohol  and  by  the  use  of  some  mild  refrigerant  mixture 
like  the  following : 

R.    Tincturae  aconiti "TTixxiv. 

Spiritus  aetheris  nitrosi f^v 

Liquoris  ammonii  acetatis  .    .     q.  s.  ad  f^iij. — M. 
SiG. — A  dessertspoonful  every  two  hours  for  a  child  of  four  years. 

TYPHOID  FEVER* 

(Enteric  Fever  ;  Typhus  Abdominalis.) 

Definition. — An  acute  infectious  disease,  excited  by  a 
special  bacillus,  characterized  anatomically  by  definite  lesions 
in  Peyer's  patches,  mesenteric  glands,  and  spleen  ;  and  mani- 
fested clinically  by  fever,  headache,  delirium,  abdominal  dis- 
tention and  tenderness,  diarrhea,  enlargement  of  the  spleen, 
and  a  rose-colored  rash. 

etiology. — Early  adult  life  (second  and  third  decades), 
individual  susceptibility,  either  acquired  or  hereditary,  and 
bodily  fatigue  are  predisposing  factors.  The  disease  is  most 
prevalent  during  the  late  summer  and  early  fall. 

The  exciting  cause  is  the  Bacillus  typhosus.  To  produce 
enteric  fever  it  must  gain  access  through  the  ahmentary 
canal.     The  fecal  discharges  and  the  urine  of  the  patient  are 


280  ACUTE  INFECTIOUS  DISEASES. 

the  source  of  the  contagion,  and  drinking-water  contami- 
nated by  them  is  the  chief  medium  of  transmission.  Milk 
contaminated  after  leaving  the  cow  is  a  fruitful  source  of  in- 
fection. Excremental  contamination  may  cause  infection 
also  through  the  medium  of  certain  articles  of  food,  such  as 
oysters,  celery,  and  lettuce.  Flies  may  be  an  important 
agent  in  disseminating  the  disease.  Occasionally  nurses, 
physicians,  and  washerwomen  are  infected  directly. 

Pathology. — The  characteristic  lesions  are  found  in  the 
abdominal  lymphatics,  namely,  in  Peyer's  patches,  solitary 
glands,  and  mesenteric  glands.  The  changes  in  Peyer's 
glands  are  best  studied  in  the  lower  part  of  the  ileum,  which 
should  be  opened  on  the  side  of  the  mesenteric  attachment. 

In  the  first  few  days  the  glands  are  swollen  and  hyperemic  ; 
later  there  is  a  marked  cell-proliferation,  the  blood-vessels 
are  compressed,  and  the  glands  become  pale  and  prominent 
(medullary  infiltration).  If  the  disease  advances,  necrosis 
sets  in,  the  glands  becoming  yellow  and  soft.  In  a  few  days 
the  necrotic  tissue  is  discharged,  leaving  an  oval,  ulcerated 
surface  with  somewhat  irregular  margins,  and  a  smooth 
base  formed  by  the  submucous  coat,  muscular  coat,  or  peri- 
toneum. 

In  the  fourth  week  cicatrization  begins,  and  the  gland  is 
ultimately  replaced  by  a  smooth  depressed  scar. 

In  addition  to  these  glandular  lesions  the  mucous  mem- 
brane of  both  large  and  small  intestines  shows  catarrhal 
changes. 

In  mild  cases  the  stage  of  ulceration  may  not  be  reached, 
the  proliferated  cells  being  removed  by  fatty  degeneration 
and  absorption  without  rupture  of  the  gland.  The  solitary 
and  mesenteric  glands  pass  through  similar  changes,  but  the 
latter  rarely  rupture.  Other  lesions  are  found  that  are  not 
characteristic.  The  spleen  is  soft  and  swollen.  The  liver, 
kidneys,  and  heart  reveal  parenchymatous  degeneration. 
The  respiratory  tract  is  commonly  the  seat  of  catarrhal  in- 
flammation. 

In  rare  instances  there  appears  to  be  a  general  infection 
without  lesions  of  the  intestinal  glands  {typhoid  septicemia). 

Period  of  Incubation. — Two  to  three  weeks. 


TYPHOID  FEVER, 


281 


Symptoms. — Prodromal  Symptoms. — These  consist  in 
gradual  weakness,  headache,  vague  pains,  nose-bleed,  and 
often  slight  diarrhea. 

The  Attack. — Fever. — The  temperature  rises  gradually, 
reaching  its  maximum  (104°- 105°  F.)  by  the  end  of  the  first 
week;  it  remains  at  this  elevation  for  another  period  of  from 
one  to  two  weeks,  when  a  gradual  defervescence  begins  and 
occupies  a  third  period  lasting  from  one  to  two  weeks. 
Throughout  its  course  the  fever  is  characterized  by  marked 
daily  remissions,  the  evening  temperature  being  from  one 
to  three  degrees  higher  than  the  morning. 

In  some  cases,  especially  in  the  young,  the  temperature 
rises  quite  abruptly.  Slight  diurnal  remissions  indicate  a 
protracted   case.     As  defervescence   advances  the  tempera- 


FlG.  13. — Temperature-curve  in  typhoid  fever. 


ture  becomes  more  irregular ;  the  remissions  are  more  de- 
cided, and  not  infrequently  the  higher  temperature  is  recorded 
in  the  morning.  An  abrupt  fall  of  several  degrees  should 
suggest  intestinal  hemorrhage  or  perforation. 

Respiratoiy  Symptoms. — These  include  hurried  breathing, 
slight  cough,  and  bronchial  rales. 

Circulatory  Symptoms. — The  pulse  becomes  rapid,  weak, 
and  dicrotic.  The  rapidity  is  often  less  than  such  tempera- 
tures generally  produce.  The  heart-sounds  become  feeble". 
The  first  may  be  especially  weak,  and  resembles  the  second.^ 

The  Face. — The  expression  is  dull  and  heavy,  the  cheeks 
are  somewhat  flushed,  the  conjunctivae  are  clear,  and  the 
pupils  dilated. 

TJie  tongue  is  tremulous  ;  at  first  it  is  red  at  the  tip  and 
edges,  and  covered  posteriorly  with  a  whitish  fur.     In  severe 


282  ACUTE  INFECTIOUS  DISEASES, 

cases  the  tongue  becomes   dry,  brown,  and  fissured,  and 
sordes  collect  on  the  teeth. 

The  Stomach. — Gastric  symptoms  are  not  common,  but 
obstinate  vomiting  sometimes  develops  and  becomes  a  serious 
complication. 

Intestinal  Symptoms. — The  abdomen  is  distended.  Ten- 
derness is  frequently  noted  on  palpation ;  it  may  be  general 
or  confined  to  the  right  iliac  fossa.  Gurgling  may  also  be 
detected  in  the  latter  region,  but  it  has  Httle  significance. 
Diarrhea  is  generally  present,  though  it  is  not  a  constant 
symptom.  The  discharges  vary  in  number  from  three  to 
six  or  more  a  day ;  they  are  thin,  offensive,  and  of  a  yel- 
lowish color  (likened  to  pea-soup)  ;  on  standing,  a  turbid 
Hquid  rises  to  the  top  and  a  granular  sediment  falls  to  the 
bottom. 

The  Eruption. — This  appears  from  the  seventh  to  the  ninth 
day,  and  is  most  abundant  on  the  abdomen,  though  it  is 
not  infrequently  observed  on  the  chest  and  back.  It  is 
composed  of  small,  slightly  elevated,  rose-colored  spots  that 
disappear  on  pressure.  It  comes  out  in  successive  crops 
over  several  days.  It  may  be  absent  particularly  in  the  old 
and  very  young.  Rarely,  in  malignant  cases,  is  the  eruption 
petechial. 

Sudamina  are  also  noted,  and  result  from  free  perspiration. 

Spleitic  enlargement  \s  rarely  absent.  Rupture  has  occurred 
in  a  few  instances. 

Nervous  Symptoms. — In  mild  cases  apathy,  headache,  and 
slight  deafness  may  be  the  only  nervous  symptoms.  In 
severe  cases  there  maybe  muttering  delirium,  stupor, twitch- 
ing of  the  tendons  (subsultus  tendinum),  picking  at  the  bed- 
clothes or  imaginary  objects  (carphologia),  and  coma. 

The  Blood. — The  red  cells  and  hemoglobin  are  reduced. 
There  is  no  leukocytosis,  but,  on  the  contrary,  leukopenia. 

Widal  Reaction. — Blood-serum  of  typhoid  patients  when 
mixed  with  a  fresh  bouillon-culture  of  the  typhoid  bacillus, 
after  the  lapse  of  a  few  hours,  clears  the  liquid  and  throws 
down  a  flocculent  precipitate.  Microscopic  examination 
shows  that  this  precipitation  is  due  to  a  loss  of  the  motility 
of  the  bacilli  and  their  agglutination  or  aggregation  in  clumps. 


TYPHOID  FEVER  283 

The  reaction  does  not  appear,  as  a  rule,  before  the  end  of  the 
seventh  or  eighth  day,  and  may  persist  for  several  months  or 
years  after  recovery.  It  can  be  obtained  from  dried  blood 
or  from  blood  collected  in  a  glass  tube  of  small  caliber.  As 
a  means  of  diagnosis  it  is  reliable  only  when  the  serum  is 
mixed  with  the  bouillon-culture  in  no  greater  proportion  than 
I  to  40.  Of  2283  typhoid  cases,  95.57  per  cent,  yielded  the 
reaction;  of  1365  non-typhoid  cases,  there  was  no  reaction 
in  98.4  per  cent, 

TJie  urine  is  febrile  and  often  slightly  albuminous.  In 
many  cases  (20  per  cent.)  it  contains  typhoid  bacilli.  Reten- 
tion is  common. 

Co7ivalescence  is  marked  by  anemia,  falling  of  the  hair, 
desquamation  of  the  cuticle,  and  sometimes  by  mental  en- 
feeblement. 

Varieties. — Mild  Typhoid. — There  is  moderate  fever  with 
marked  remissions  ;  the  diarrhea  is  slight ;  nervous  symp- 
toms are  often  absent ;  the  rash  is  usually  present,  and  may 
be  abundant. 

Abortive  Typhoid. — There  is  an  abrupt  onset  with  severe 
symptoms,  but  convalescence  follows  in  from  ten  days  to 
two  weeks. 

Walking  Typhoid. — The  symptoms  are  mild,  and  often  dis- 
regarded by  the  patient,  who  refuses  to  go  to  bed  ;  but  grave 
symptoms  may  develop  suddenly,  and  death  from  perforation 
is  not  uncommon. 

Typhoid  in  Children. — The  rash  is  often  absent ;  the  fever 
rises  abruptly ;  cerebral  symptoms  are  frequently  marked. 

Complications.- — Any  symptom  aggravated  constitutes  a 
complication  ;  thus  high  fever,  excessive  diarrhea,  and  tym- 
panites may  be  troublesome  complications. 

HemorrJiage. — This  usually  occurs  during  the  third  week, 
and  is  indicated  by  a  sudden  fall  of  temperature,  followed  by 
dark-red  or  tarry  stools. 

Perforation. — This  occurs  in  about  2  per  cent,  of  all  cases. 
It  may  be  recognized  by  sudden  localized  pain  and  tender- 
ness, fall  of  temperature,  leukocytosis,  marked  tympanites, 
disappearance  of  the  liver  dulness,  vesical  irritation,  and 
signs  of  peritonitis. 


284  ACUTE   INFECTIOUS  DISEASES. 

Pneumonia  (croupous  or  catarrhal)  and  hypostatic  conges- 
tion of  the  lungs  are  common  complications. 

Among  the  less  frequent  complications  or  sequelae  may 
be  mentioned :  Neuritis,  nephritis,  pyelitis,  cholecystitis,  ap- 
pendicitis, otitis  media,  periostitis,  parotitis,  phlebitis,  and  tem- 
porary insanity. 

Relapse  and  Recrudescence. — Relapses  are  quite  com- 
mon ;  they  repeat  the  symptoms  of  the  original  attack,  but 
they  are  generally  milder  and  of  shorter  duration,  and  seldom 
prove  fatal. 

Recrudescence. — This  is  a  sudden  temporaiy  elevation  of 
temperature  occurring  during  convalescence,  and  is  not  asso- 
ciated with  a  return  of  the  other  symptoms.  It  is  usually 
due  to  constipation,  excitement,  or  irritating  food. 

Diagnosis. — Acute  miliary  tuberculosis  often  closely  re- 
sembles typhoid  fever.  In  tuberculosis  the  temperature  is 
generally  more  irregular ;  the  abdominal  symptoms  are  less 
marked ;  pulmonary  symptoms,  especially  dyspnea,  are  more 
marked ;  the  rash  is  absent ;  the  Widal  reaction  is  absent ; 
tubercles  may  be  detected  on  the  retina ;  and  symptoms  of 
basilar  meningitis  may  be  present,  such  as  irregular  pupils, 
ptosis,  and  strabismus. 

Ulcerative  Endocarditis. — The  diagnosis  may  be  impossible, 
but  the  following  features  would  suggest  endocarditis  :  The 
history  of  a  primary  disease  which  might  induce  ulcerative 
endocarditis ;  irregular  fever ;  intercurrent  rigors  ;  marked 
leukocytosis ;  precordial  pain  and  endocardial  murmurs ; 
and  the  absence  of  a  rose-colored  rash,  of  the  Widal  reac- 
tion, and  of  marked  abdominal  symptoms. 

Enteritis. — The  absence  of  high  fever,  of  eruption,  of 
splenic  enlargement,  of  epistaxis,  and  of  bronchial  catarrh 
will  serve  to  distinguish  enteritis  from  typhoid  fever. 

Meningitis. — The  abrupt  onset,  the  early  development  of 
cerebral  symptoms,  the  irregular  fever,  the  leukocytosis,  and 
the  absence  of  the  characteristic  rash,  of  abdominal  symptoms, 
and  the  Widal  reaction  will  indicate  meningitis. 

Prognosis. — The  prognosis  should  always  be  guarded. 
No  case  is  too  mild  to  prove  fatal,  and  no  case  is  too  severe 
to   recover.     The    mortality   varies   in    different   epidemics. 


TYPHOID   FEVER.  285 

Under  present  methods  of  treatment  the  average  mortality  is 
about  8  per  cent. 

Continued  high  fever  with  shght  diurnal  remissions,  exces- 
sive diarrhea,  severe  cerebral  symptoms,  and  repeated  hemor- 
rhages are  unfavorable  features. 

Treatment. — As  soon  as  the  nature  of  the  disease  is 
recognized  the  patient  should  be  confined  to  bed.  The  room 
should  be  large  and  airy,  and  provided  with  efficient  means 
of  securing  thorough  ventilation.  The  temperature  of  the 
room  should  be  maintained  between  65°  and  70°  F.  The 
bed-pan  must  be  used  from  the  beginning  until  convalescence 
is  well  advanced.  The  stools  and  urine  should  be  rendered 
innocuous  before  being  disposed  of  This  may  be  done  by 
treating  the  evacuation  with  twice  its  volume  of  a  i  per 
cent,  solution  of  chlorinated  Hme  or  a  5  per  cent,  solution  of 
carbolic  acid,  and  allowing  it  to  stand  in  a  covered  vessel  for 
two  hours  before  emptying  it  into  the  closet.  Soiled  clothing 
should  be  thoroughly  boiled. 

The  diet  should  be  liquid  or  semisoHd,  unirritating,  and 
easily  assimilable.  As  a  rule,  milk  is  the  best  food.  Most 
patients  will  be  able  to  take  from  2  to  4  pints  in  the  twenty- 
four  hours,  given  in  portions  of  from  4  to  6  ounces  every 
two  or  three  hours.  It  is  generally  advisable  to  dilute  the 
milk  with  Hme-water.  If  curds  appear  in  the  stools,  the 
quantity  of  milk  should  be  reduced.  Among  other  permis- 
sible articles  may  be  mentioned  buttermilk,  kumiss,  junket, 
milk-whey,  ice-cream,  albumin-water,  oyster,  mutton,  or 
chicken-broths,  chicken  jelly,  and  consomme.  The  return 
to  solids  should  not  be  commenced,  as  a  rule,  until  the 
temperature  has  been  normal  for  a  week.  Cool  water  or 
ice  will  be  required  to  allay  thirst,  and  even  if  the  latter  is 
absent,  it  is  well  to  give  one  or  the  other  at  regular  intervals. 
When  the  first  sound  of  the  heart  weakens  and  the  pulse 
becomes  soft,  stimulants  should  be  administered.  It  is  de- 
sirable to  give  the  alcohol  with  the  milk  so  as  to  stimu- 
late the  stomach  to  digest  the  latter,  and  at  the  same  time 
to  diminish  the  number  of  administrations  of  food  and  medi- 
cine.    From  4  to  8  ounces  of  brandy  or  whisky  may  be  re- 


286  ACUTE  INFECTIOUS  DISEASES. 

quired  in  the  twenty-four  hours,  the  amount  being  deter- 
mined by  the  general  effect. 

The  use  of  the  cold  bath  or  the  cold  pack  will  be  found  an 
excellent  method  of  controlling  fever  and  of  preventing  the 
development  of  severe  nervous  symptoms.  It  is  especially 
valuable  as  a  stimulant  to  the  nerve-centers,  and  may  be  em- 
ployed whenever  the  temperature  exceeds  I02|^°  F.  Hemor- 
rhage and  perforation  contraindicate  its  use  (see  page  276). 

Heart-failwe. — Cold  bathing  and  the  timely  use  of  alco- 
hol do  much  to  guard  against  heart-failure.  When  the  ten- 
dency to  cardiac  failure  is  pronounced,  strychnin  may  be 
given  in  doses  of  from  -^-^  to  -^  grain  every  three  or  four 
hours.  In  severe  cases  the  drug  should  be  given  hypoder- 
mically.  Digitalis  or  strophanthus  may  also  be  tried,  but  in 
the  presence  of  fever  these  remedies  often  prove  ineffectual. 
If  collapse  is  threatened,  ether,  alcohol,  or,  better  still,  cam- 
phor (i  to  2  grains  in  sterile  olive  oil)  may  be  given  sub- 
cutaneously  every  two  or  three  hours. 

Diarrhea. — When    the    diarrhea    exceeds    three    or   four 
stools  a  day,  a  suppository  of  opium  (J  to  I  grain)  may  be 
used  once  or  twice  daily.     If  the  diarrhea  be  troublesome, 
bismuth   subnitrate   or  silver  nitrate  may  be  given  by  the    I 
mouth  in  combination  with  opium  : 

R-     Morphinse  sulphatis gr.  j  1 

Orphol  .    , o ^iss  1 

Bismuthi  subnitratis ^iij. — M. 

riant  chartulse  No.  xv.  I 

SiG. — One  powder  every  three  or  four  hours. 

R .     Argenti  nitratis gr-  iij  i 

Pulveris  opii gr.  vj. — M.  I 

Fiant  pilulse  xij. 

SiG. — One  pill  eveiy  three  or  four  hours. 

In  very  obstinate  cases  copper  sulphate  with  opium  in  pill 
proves  efficacious. 

Constipation. — This  may  be  relieved  by  enemas  of  soap 
and  water  or  by  the  administration  of  fractional  doses  of 
calomel. 

Tympanites. — This  may  be  relieved  by  the  application  of 
turpentine  stupes  and  the  internal  administration  of  some 
antiseptic,  such  as  salol,  creosote,  or  bismuth-beta-naphthol. 


TYPHUS  FEVER.  28/ 

When  extreme,  a  soft  rectal  tube  may  be  introduced  into 
the  bowel. 

Hemorrhage. — Absolute  rest  is  imperative.  Cold  bathing 
should  be  suspended.  It  is  advisable  to  elevate  the  foot  of 
the  bed.  An  ice-bag  may  be  applied  with  advantage  to  the 
right  iHac  region,  and  ice  may  be  given  to  suck.  The  best 
drug  is  morphin  (^  to  \  grain)  hypodermically.  Ergot  is 
of  doubtful  value.  In  cases  of  recurrent  hemorrhage  gelatin 
may  be  given  subcutaneously,  by  the  mouth,  or  by  the 
bowel. 

Insomnia. — Opium  is  generally  the  best  hypnotic.  In 
some  cases,  however,  sodium  bromid  or  chloralamid  acts 
better. 

Delirium  is  best  managed  by  hydrotherapy.  Low,  mut- 
tering delirium  usually  calls  for  stimulants.  An  ice-cap  is 
useful.  Camphor  or  musk  may  be  tried  :  the  former  is  best 
given  hypodermically,  the  latter,  by  the  bowel.  In  active  or 
violent  delirium  no  drug  is  so  generally  useful  as  morphin. 

Perforation. — Recovery  from  peritonitis  is  so  exceedingly 
rare  under  medicinal  treatment  that  operative  interference  is 
called  for  in  all  cases  that  are  not  obviously  moribund.  The 
operation  should  be  done  at  the  earliest  possible  moment. 
Keen  has  collected  83  cases  with  16  recoveries. 


TYPHUS  FEVER. 

(Ship  Fever;  Jail  Fever.) 

Definition. — An  acute  contagious  disease  unassociated 
with  any  characteristic  lesions,  and  manifested  by  great 
prostration,  a  petechial  rash,  marked  nervous  symptoms, 
and  high  fever  that  defervesces  by  crisis  in  from  twelve  to 
fourteen  days. 

etiology. — It  is  excited  by  an  unknown  poison  that  is 
capable  of  being  carried  in  clothes  (fomites).  It  is  rare  in 
America,  but  not  uncommon  in  England,  Ireland,  and 
Russia.  Bad  food,  impure  water,  overcrowding,  and  foul 
air  are  predisposing  factors. 

Pathology. — There  are    no  characteristic  lesions.     As 


288  ACUTE   INFECTIOUS  DISEASES. 

in  other  fevers,  the  Hver  and  spleen  are  swollen,  and  the 
tissues  reveal  parenchymatous  and  fatty  degeneration.  The 
blood  is  dark  and  fluid. 

Period  of  Incubation. — From  a  few  days  to  two 
weeks. 

Symptoms. — ^Typhus  fever  begins  abruptly  with  pain  in 
the  head,  back,  and  limbs ;  extreme  prostration ;  and  fever 
that  reaches  its  maximum  (104°  to  105°  F.)  in  from  two  to 
three  days.  The  temperature  remains  high  until  the  tw^elfth 
or  fourteenth  day,  when  it  falls  by  crisis. 

The  pulse  is  rapid,  weak,  and  often  dicrotic.  The  tongue 
is  at  first  moist  and  covered  with  a  whitish  fur,  but  it  soon 
becomes  dry  and  brown. 

.The  face  is   dusky;   the  conjunctivae  are    injected;    the 
pupils  are  contracted. 

Nervous  Symptoms. — In  severe  cases  these  are  prominent, 
and  consist  of  headache,  stupor,  delirium,  subsultus  tendi- 
num,  carphologia,  and  coma-vigil. 

The  Eruption. — ^About  the  fourth  or  fifth  day  rose-colored 
spots  appear  over  the  body ;  these  rapidly  become  hemor- 
rhagic or  petechial,  and  fail  to  disappear  on  pressure.  There 
i3  a  distinct  relation  between  the  amount  of  eruption  and 
the  severity  of  the  attack.  In  addition  to  this  "  mulberry 
rash  "  there  is  often  a  diffuse,  dark-red,  subcuticular  mott- 
ling. 

G astro-intestinal  Symptoms. — The  stomach  is  retentive  and 
the  bowels  are  constipated. 

Urine. — The  urine  is  scanty,  high-colored,  and  often  albu- 
minous. 

Complications. — These  are  not  very  common,  but  ca- 
tarrhal pneumonia,  localized  gangrene,  neuritis,  nephritis, 
and  abscesses  may  occur. 

Diagnosis. — Cerebrospinal  Meningitis. — In  this  affection 
the  pain  in  the  back  is  greater ;  the  fever  is  much  more 
irregular;  there  is  greater  tendency  to  opisthotonos  and 
facial  palsies ;  vomiting  is  much  more  common,  and  the 
eruption,  though  it  may  resemble  that  of  typhus,  is  incon- 
stant and  without  a  special  time  for  appearing. 

Typhoid  Fever. — The  resemblance  is  in  the  nervous  phe- 


RELAPSING   FEVER.  289 

nomena  only.  In  typhoid  fever  the  fever  rises  and  falls  very 
gradually;  the  eruption  appears  later,  remains  rose-red,  and 
does  not  become  petechial ;  the  face  is  not  dusky ;  the  eyes 
are  not  injected ;  the  blood  yields  the  Widal  reaction,  and 
there  are  marked  abdominal  symptoms. 

Prognosis. — The  mortality  varies  in  different  epidemics. 


Fig.  14. — Temperature-chart  of  typhus. 

It  may  exceed  20  per  cent.     Advanced  years  and  alcohol- 
ism render  the  prognosis  very  grave. 

Treatment. — The  patient  should  be  isolated,  and  all 
the  excreta  disinfected.  The  general  treatment  is  the  same 
as  that  of  typhoid  fever. 

RELAPSING  FEVER. 

(Spirillum  Fever;  Famine  Fever.) 

Definition. — An  acute  contagious  disease  excited  by 
the  Spirochaeta  Obermeieri,  and  characterized  by  recurring 
paroxysms  of  high  fever  lasting  for  from  five  to  seven  days. 

Etiology. — The  exciting  cause  is  the  Spirochaeta  Ober- 
meieri, a  spiral-shaped  microbe  three  or  four  times  as  long 
as  the  diameter  of  a  red  blood-corpuscle.  Bad  water,  poor 
food,  overcrowding,  and  foul  air  predispose  to  epidemics. 
The  disease  is  highly  contagious. 

Pathology. — There  are  no  characteristic  lesions.  The 
liver  and  spleen  are  enlarged,  and  the  latter  is  frequently 
the  seat  of  infarctions.  There  is  usually  catarrhal  inflam- 
mation of  the  stomach  and  bile-ducts.  The  spirochaeta  is 
found  in  the  blood  during  life,  but  only  during  the  parox- 
ysms ;  after  death  it  is  found  in  all  the  organs. 
19 


290  ACUTE   INFECTIOUS  DISEASES. 

Period  of  Incubation. — From  two  days  to  two  weeks. 

Symptoms. — The  disease  begins  abruptly  with  a  chill, 
followed  by  fever,  which  reaches  its  maximum  (io5°-io6° 
F.)  in  twenty-four  hours,  and  remains  high  for  from  five  to 
•seven  days,  when  it  falls  by  crisis.  After  an  intermission 
of  five  or  six  days  it  again  rises  rapidly  and  remains  high 
for  a  similar  period.  Convalescence  usually  begins  at  the 
end  of  the  second  paroxysm,  but  it  may  not  begin  until 
after  the  third  or  fourth.  Other  noteworthy  symptoms  are 
intense  pains  in  the  head,  back,  and  joints,  and  the  presence 
of  the   spirochaeta  in   the  blood.      Gastric   irritability  and 


Fig.  15. — Temperature  curve  in  relapsing  fever. 

jaundice  are  also  common.  Not  infrequently  there  is  an 
ecchymotic  rash. 

Complications. — The  chief  complications  are  hyper- 
pyrexia, nephritis,  pneumonia,  ophthalmia,  and  hemorrhage 
from  the  kidneys,  stomach,  or  bowels. 

Diagnosis. — The  characteristic  febrile  paroxysms  with 
the  long  intermissions  and  the  presence  of  the  spirochaeta 
in  the  blood  are  the  distinctive  features. 

Prognosis. — Favorable  in  uncomplicated  cases. 

Treatment. — As  in  all  contagious  diseases,  isolation, 
free  ventilation,  and  disinfection  of  excreta  and  clothing  are 
important  safeguards  against  the  spread  of  the  virus.  The 
treatment  is  purely  symptomatic.  Absolute  rest,  good 
nursing,  and  proper  diet  will  do  much  to  avert  complica- 
tions. Vomiting  may  be  controlled  by  carbonated  water, 
wine  of  ipecac  (i  minim),  diluted  hydrocyanic  acid  (i  or  2 
drops),  or  cocain  {\  grain) ;  the  fever  by  cold  sponging ; 
and  the  severe  pains  by  morphin  or  phenacetin. 


CEREBROSPINAL   FEVER.  29 1 

CEREBROSPINAL  FEVER. 
(Epidemic  Cerebrospinal  Meningitis;  Spotted  Fever.) 

Definition. — A  specific  infectious  disease  characterized 
anatomically  by  inflammation  of  the  cerebrospinal  meninges, 
and  clinicall)'  by  intense  pain  in  the  head,  back,  and  limbs, 
convulsions,  irregular  fever,  and  frequently  by  a  petechial 
eruption. 

!^tiolog"y. — The  disease  may  be  sporadic  or  epidemic. 
Overcrowding,  poor  food,  foul  air,  and  bad  dnnking-water 
predispose  to  epidemics.  Outbreaks  are  most  common 
in  the  winter  and  spring.  The  young  are  more  susceptible 
than  the  old.  The  disease  is  not  commonly  regarded  as 
transmissible,  but  cases  have  recently  been  reported  which 
furnish  strong'  evidence  of  its  contagiousness. 

The  Excitijig  Cause. — The  Diplococcus  intracellularis  of 
Weichselbaum  is  the  specific  cause  of  the  disease.  It  ap- 
pears in  the  polymorphonuclear  leukocytes  of  the  exudate, 
and  may  be  gotten  from  the  nasal  secretion  and  the  fluid 
obtained  by  spinal  puncture. 

Pathology. — In  most  cases  the  membranes  of  the  brain 
and  cord  are  deeply  congested  and  opaque.  Lymph  and 
pus  are  found  both  at  the  base  and  on  the  convexity  of  the 
brain,  especially  in  the  fissures  and  along  the  blood-vessels. 
The  spinal  meninges  present  similar  changes,  the  posterior 
surface  of  the  cord  being  particularly  involved. 

The  liver  and  spleen  are  engorged,  and  the  muscles 
reveal  granular  degeneration.  In  rapidly  fatal  cases  the 
lesions  may  be  very  slight. 

Symptoms. — Common  Form. — The  disease  generally  be- 
gins abruptly  with  a  chill,  followed  by  vomiting  and  excru- 
ciating pain  in  the  head,  back,  and  limbs.  The  muscles  of 
the  neck  and  back  become  rigid  and  contracted,  so  that  the 
head  is  bent  backward  and  the  back  is  straightened  ;  in 
severe  cases  the  body  may  be  arched  in  a  state  of  opis- 
thotonos.   Kernig's  sign  is  an  almost  constant  phenomenon.^ 

^  This  consists  in  an  inability  to  straighten  the  leg  completely  when  the 
patient  is  in  the  recumbent  posture  and  the  thigh  is  liexed  at  a  right  angle 
with  the  pelvis. 


292  ACUTE   INFECTIOUS  DISEASES, 

Delirium  is  rarely  absent,  and  in  severe  cases  it  is  followed 
by  stupor  and  coma. 

Involvement  of  the  Crdfiial  Nerves. — Pressure  of  the  exu- 
date upon  the  cranial  nerves  may  produce  the  following 
symptoms  :  Nystagmus  (tremor  of  the  eyeball)  ;  strabismus  ; 
ptosis  ;  irregular,  sluggish  pupils ;  and  partial  deafness  or 
blmdness. 

Involvement  of  the  Spinal  Nerves. — There  is  extreme 
cutaneous  hyperesthesia,  so  that  the  sHghtest  touch  excites 
pain.  The  muscles  of  the  extremities  are  stiff  and  may 
twitch,  but  are  rarely  palsied.  The  patellar  reflex  is  usually 
diminished.  The  joints  are  occasionally  red,  swollen,  and 
painful. 

Febrile  Symptoms. — The  temperature  is  irregular  in  its 
course  and  indefinite  in  its  duration ;  ordinarily  it  ranges  be- 
tween 101°  and  103°  F.,  but  in  some  cases  it  is  almost 
normal,  and  in  others  it  is  very  high.  The  pulse  is  rapid 
and  full;  the  bowels  are  constipated;  and  the  urine  may 
contain  albumin  and  sugar.  There  is  usually  rapid  emacia- 
tion.    Polyuria  is  an  occasional  symptom. 

The  Eruption. — The  eruption  is  neither  constant  nor  pecu- 
liar. In  many  cases  a  blotchy  purpuric  rash  appears  over 
the  entire  body.  Herpes  facialis  is  also  frequently  ob- 
served. In  other  cases  urticaria  or  a  roseolar  or  erythema- 
tous rash  appears. 

The  Blood. — Leukocytosis  is  alw^ays  present. 

Lumbar  Punctiire. — In  a  large  proportion  of  the  cases 
diplococci  are  found  either  on  microscopic  examination  or 
by  culture. 

The  duration  is  from  a  few  hours  to  several  weeks.  In 
favorable  cases  recovery  is  always  slow. 

Fulminant  Form. — There  is  an  abrupt  onset,  with  a  chill, 
followed  by  vomiting,  headache,  moderate  fever,  convul- 
sions, a  petechial  or  purpuric  rash,  and  death  in  a  few  hours 
from  collapse. 

Abortive  Form. — The  disease  begins  abruptly  with  grave 
symptoms,  but  terminates  in  a  few  days  in  recovery. 

Intermittent  Form. — The  fever  is  characterized  by  inter- 
missions or  marked  remissions  that  occur  daily  or  every 
other  day. 


CEREBROSPINAL   FEVER.  293 

Diagnosis. — Typhoid  Fever. — The  gradual  onset,  the 
regular  fever,  the  diarrhea  and  tympanites,  the  Widal  reac- 
tion, and  the  absence  of  rigidity,  of  intense  pain  in  the 
back  and  limbs,  of  facial  palsies,  of  leukocytosis,  of  Kernig's 
sign,  and  of  herpes,  will  serve  to  distinguish  typhoid  from 
cerebrospinal  fever. 

Typhus  Fever. — The  regular  fever,  the  absence  of  intense 
pain  in  the  back  and  limbs,  of  facial  palsies,  of  Kernig's 
sign,  and  of  muscular  rigidity  will  distinguish  typhus  from 
cerebrospinal  fever. 

Acute  articular  rheumatism  may  resemble  cerebrospinal 
meningitis,  but  the  early  involvement  of  the  joints,  the  acid 
sweats,  and  the  absence  of  rigidity,  of  eruption,  and  of  facial 
palsies,  will  distinguish  it  from  cerebrospinal  meningitis. 

Tuberculous  Meningitis. — In  this  disease  the  onset  is  less 
abrupt ;  there  is  less  tendency  to  opisthotonos ;  herpes  is 
rare;  petechiae  are  always  absent.  Lumbar  puncture  affords 
a  reliable  means  of  diagnosis  and  a  primary  focus  of  tuber- 
culosis can  generally  be  detected  elsewhere  in  the  body. 

Prognosis. — The  mortality  varies  in  different  epidemics 
from  20  to  80  per  cent.  The  prognosis  should  always  be 
guarded ;  the  mildest  cases  may  prove  fatal.  Severe  cere- 
bral symptoms  usually  indicate  a  fatal  termination. 

Complications  and  Sequelae. — These  include  defective 
vision  from  inflammation  of  the  cornea  or  retina  or  from 
atrophy  of  the  optic  nerve ;  defective  hearing  from  inflam- 
mation of  the  auditory  nerve  or  from  suppurative  inflamma- 
tion of  the  internal  or  middle  ear ;  pneumonia ;  arthritis ; 
aphasia  ;  peripheral  palsies  ;  imbecility ;  chronic  hydroceph- 
alus ;  and  persistent  headache  from  chronic  meningitis. 

Treatment. — Cerebrospinal  fever  is  probably  not  con- 
tagious, hence  rigid  isolation  is  not  usually  regarded  as 
absolutely  necessary.  It  is  advisable,  however,  to  disinfect 
the  discharges,  bed-linen,  etc.  The  sick-room  should  be 
quiet,  darkened,  and  well  ventilated.  The  diet  should  be 
hquid  and  supporting.  In  some  cases,  in  order  to  secure 
the  ingestion  of  enough  nourishment,  it  may  be  necessary 
to  resort  to  nutrient  enemas  or  forced  feeding  by  means 
of  a  stomach-tube.  Cardiac  failure  must  be  combated  by 
stimulants,  of  which  the  best  are  whisky  and  brandy. 


294  ACUTE   INFECTIOUS  DISEASES. 

In  sthenic  cases  the  withdrawal  of  several  ounces  of  blood 
by  wet-cups  applied  along  the  cervical  vertebrae  may  prove 
useful.  Cold  applied  to  the  head  and  along  the  spine 
affords  considerable  relief  Blisters  to  the  nape  of  the  neck 
are  of  doubtful  value,  at  least  during  the  irritative  stage. 
Morphin  hypodermically  is  the  best  drug  for  the  relief  of 
pain,  restlessness,  spasms,  and  insomnia.  In  mild  cases 
bromids  may  suffice. 

Fever  is  controlled  best  by  cold  sponging  or  the  cold 
pack,  or,  if  the  temperature  is  very  high,  by  systematic  cold 
bathing.  Repeated  lumbar  punctures  have  been  found  use- 
ful in  relieving  excruciating  headache,  delirium,  somnolence, 
and  coma. 

Tonics — iron,  strychnin,  and  cod-liver  oil — are  generally 
indicated  during  convalescence.  Local  palsies  will  require 
massage  and  electricity. 


MALARIAL   FEVER. 

(Chills  and  Fever ;  Fever  and  Ague ;  Paludism.) 

Definition. — An  infectious  disease,  excited  by  a  proto- 
zoan parasite — the  hematozoon  or  Plasmodium  malariae  of 
Laveran,  and  characterized  by  splenic  enlargement,  fever 
with  periodic  intermissions  or  remissions,  chills,  and  anemia. 

!]^tiologfy. — Man  becomes  infected  with  the  organism  of 
malaria  usually,  if  not  invariably,  through  the  bite  of  certain 
mosquitos,  namely,  those  belonging  to  the  genus  Anopheles, 
which  serve  as  hosts  for  the  parasite.  The  usual  source 
from  which  the  mosquito  derives  the  parasite  is  man.  The 
conditions  predisposing  to  infection  are  those  which  are 
favorable  to  mosquito  life,  namely,  high  temperature,  humid- 
ity, and  collections  of  water  undisturbed  by  winds  or  cur- 
rents. 

Persons  living  in  high-lying  localities  are  less  liable  to 
infection  than  those  living  in  low  lands,  because  the  mos- 
quito does  not  rise  high  above  the  ground.  Malaria  is 
more  apt  to  be  contracted  at  night  than  during  the  day,  be- 
cause   most    species    of  anopheles    are    nocturnal    in    their 


MALARIAL    FEVER.  295 

habits.       Males  being  more  exposed  to  infection  are  more 
often  attacked  than  females. 

Pathology. — Three  forms  of  malarial  parasites  have  been 
distinguished:  (i)  Tertian;  (2)  quartan;  (3)  estivo-autumnal. 

Tertian  Parasite. — Several  hours  after  a  chill  small  hyaline 
bodies  with  ameboid  movements  appear  in  some  of  the  red 
corpuscles.  Later  pigment-granules  in  considerable  quantity 
collect  around  the  periphery  of  the  parasite.  During  this 
time  the  organism  increases  in  size  and  the  corpuscle  grows 
paler.  Eventually  the  parasite  may  fill  almost  entirely  the 
red  cell.  After  a  time  the  pigment  collects  in  the  center, 
the  ameboid  movements  cease  entirely,  and  segmentation  of 
the  parasite  follows,  with  the  formation  of  a  roset-like  figure 
composed  of  from  1 5  to  26  parts  or  spores.  The  red  cell 
next  ruptures,  and  the  spores  escape  in  the  plasma,  to  enter 
other  red  cells  and  go  through  the  same  cycle  of  develop- 
ment. The  paroxysms  or  chills  occur  at  the  time  of  spor- 
ulation,  and  are  doubtless  due  to  the  production  of  a  toxin. 
The  tertian  parasite  requires  forty-eight  hours  to  complete 
its  cycle  of  development ;  hence  when  a  single  group  of 
these  parasites  is  present,  paroxysms  occur  every  other  day 
(tertian  fever^.  If,  however,  two  groups  coexist  and  sporu- 
late  on  alternate  days,  a  paroxysm  occurs  daily  {qnotidian 
fever). 

Certain  mature  parasites  (sexual  forms  or  gametocytes) 
do  not  undergo  segmentation,  but  complete  the  cycle  of 
their  development  in  the  tissues  of  another  host  (mosquito). 
Spores  equivalent  to  those  resulting  from  the  segmentation 
of  the  asexual  forms  are  inoculated  into  man  by  the  bite  of 
the  insect  and  on  entering  the  red  blood-cells  develop  into 
sexual  or  asexual  forms. 

Quartan  Parasite. — This  is  less  widely  distributed  than 
the  tertian  parasite.  It  differs  from  the  latter  in  having 
coarser  but  less  abundant  pigment,  and  in  not  decolorizing 
the  red  cell.  Segmentation  occurs  in  about  seventy-two 
hours,  with  the  formation  of  from  6  to  14  spores.  One 
group  of  quartan  parasites  excites  a  chill  every  fourth  day 
{quartan  fevei').  When  two  groups  coexist,  a  chill  occurs 
on  each  of  two  successive  days,  separated  by  one  day  of 


296  ACUTE   INFECTIOUS  DISEASES. 

intermission  {double  quartan  fever).  When  three  groups 
coexist,  a  chill  occurs  every  day  {quotidian  fever). 

The  life-history  of  the  quartan  parasite  is  similar  to  that 
of  the  tertian  parasite. 

Estivo-autumual  Parasite. — The  latter  half  of  the  life-cycle 
of  this  parasite  is  carried  out  in  the  internal  organs.  The 
endocorpuscular  form  is  smaller  than  that  of  either  the 
tertian  or  the  quartan,  and  contains  much  less  pigment.  As 
the  parasite  develops  the  corpuscle  acquires  a  peculiar 
shriveled  and  "  brassy "  appearance.  Segmentation  does 
not  occur  in  the  peripheral  blood,  but  in  the  spleen  and 
other  internal  parts.  After  the  infection  has  lasted  a  week 
or  more,  crescent,  ovoid,  and  round  bodies,  with    central 


Fig.  16. ^Various  forms  of  hematozoa  :  Tertian  organisms  (Thayer  and  Hew- 
etson)  ;  a,  young  hyaline  form;  b,  hyaline  form  with  beginning  pigmentation; 
c,  pigmented  form  ;  d,  full-grown  pigmented    form  ;  e,f,g,  segmenting  forms. 

clumps  of  coarse  pigment  granules,  appear  in  the  corpuscles, 
which  by  this  time  are  scarcely  more  than  thin,  colorless 
shells.  The  crescent  and  ovoid  forms  are  gametocytes,  the 
later  evolution  of  which  occurs  in  the  tissues  of  the  mos- 
quito. The  estivo-autumnal  parasite  varies  in  the  length  of 
time  necessary  for  completing   its  developmental  cycle. 

Pathologic  !^ffects. — The  destruction  of  the  red  cells 
by  the  parasites  is  followed  by  anemia,  melanemia,  and  pig- 
mentation of  the  organs.  The  spleen  becomes  greatly  en- 
larged from  congestion.  In  chronic  cases  (malarial  cachexia) 
it  becomes  hard  and  tough  from  hyperplasia  of  the  fibrous 
tissue.  Extreme  disintegration  of  the  blood  may  occasion 
thrombosis  of  small  vessels  and  also  hemoglobinuria. 

Clinical  Varieties  of  Malaria. — The  following  clinical  forms 
are  recognized:  (i)  Intermittent  malarial  fever;  (2)  estivo- 
autumnal  fever;  (3)  pernicious  malarial  fever;  (4)  chronic 
malarial  cachexia. 


MALARIAL   FEVER.  29/ 

INTERMITTENT  MALARIAL  FEVER* 

Intermittent  malarial  fever  is  excited  by  tertian  or  quartan 
parasites.  It  is  characterized  by  paroxysms  of  fever  occur- 
ring at  definite  periods,  each  paroxysm  consisting  of  a  cold, 
a  hot,  and  a  sweating  stage. 

Cold  Stage. — This  stage  is  characterized  by  lassitude, 
aching  in  the  limbs,  and  great  chilliness.  The  features  are 
pinched ;  the  lips  are  blue ;  and  the  surface  is  cold  and 
rough  (cutis  anserina).  The  rectal  temperature,  however,  is 
high  (105°- 1 06°  F,).  Vomiting  may  occur.  The  chill  may 
last  from  a  few  minutes  to  an  hour  or  more. 

Hot  Stage. — The  surface  temperature  gradually  rises;  the 
skin  becomes  hot;  the  face  flushed ;  the  eyes  injected ;  and 
the  pulse  full  and  rapid.  The  temperature  in  the  axilla  may 
reach  106°  or  107°  F.  The  patient  complains  of  severe 
pain  in  the  head,  back,  and  limbs,  and  of  intense  thirst.  The 
urine  is  scanty  and  dark  colored.  This  stage  usually  lasts 
from  one  to  five  hours. 

Sweating  Stage. — The  fever  gradually  subsides  ;  the  pains 
grow  less,  free  perspiration  follows,  and  the  urine  becomes 
plentiful.  Within  an  hour  or  two  the  attack  is  over  and  the 
patient  falls  into  a  refreshing  sleep. 

In  addition  to  the  recurring  paroxysms,  intermittent 
malarial  fever  presents  symptoms  common  to  all  forms  of 
malarial  infection,  namely,  enlargement  of  the  spleen,  anemia, 
pigmentation  of  the  leukocytes,  and  the  presence  of  hema- 
tozoa  in  the  blood.     There  is  no  leukocytosis. 

ESTIVO-AUTUMNAL  FEVER, 
(Remittent  Fever;   Semitertian  Fever.) 

In  temperate  zones  this  type  occurs  chiefly  in  the  late 
summer  and  autumn.  In  tropical  countries,  where  it  often 
assumes  a  most  severe  form,  it  occurs  at  all  seasons. 

The  symptoms  of  estivo-autumnal  fever  are  often  quite 
irregular.  The  hot  stage  of  the  paroxysm  often  lasts 
twenty-four  or  thirty-six  hours,  or  even  longer,  and  the 
intermissions  are  very  short.  In  many  cases  there  are  no 
actual  intermissionSj,  but  simply  remissions  (remittent  fever). 


298  ACUTE   INFECTIOUS  DISEASES. 

The  chill  and  the  sweat  may  be  as  severe  as  in  intermittent 
fever,  but  usually  they  are  slight  and  of  short  duration. 
There  is  often  slight  jaundice  (bilious  remittent  fever).  In 
some  cases  there  is  mild  delirium,  making  the  condition  re- 
semble very  closely  typhoid  fever.  Prostration  is  always 
marked.  The  spleen  is  enlarged.  The  characteristic  para- 
site is  found  in  the  blood. 

PERJSfiaOUS  MALARIAL  FEVER. 

This  type  is  excited  by  the  estivo-autumnal  parasite.  It 
prevails  in  tropical  and  subtropical  countries,  and  is  rare  in 
temperate  regions.  The  second  or  third  paroxysm  may 
assume  a  pernicious  type,  but  never  the  first.  The  symp- 
toms vary  with  the  localization  of  the  parasite.  When  the 
latter  accumulate  in  the  capillaries  of  the  brain  and  men- 
inges, the  attack  may  be  manifest  by  delirium,  aphasia,  and 
rapidly  developing  coma  {comatose  type).  When  the  locali- 
zation is  gastro-intestinal,  there  may  be  vomiting  and  purg- 
ing of  serous  material,  cramps,  suppression  of  urine,  cold- 
ness of  the  surface,  profuse  sweating,  and  fatal  collapse 
{algid  type).  In  other  cases,  in  consequence  of  a  sudden 
and  intense  hemolysis,  the  paroxysms  are  associated  with 
jaundice,  bilious  vomiting,  and  hemoglobinuria.  Bleeding 
into  the  subcutaneous  tissues  and  from  the  mucous  mem- 
branes may  also  occur  (hemorrhagic  type). 

Chronic  Malarial  Cachexia. — Malarial  cachexia  may 
be  a  sequel  of  repeated  attacks  of  intermittent  or  estivo- 
autumnal  fever,  or  it  may  develop  insidiously  as  a  primary 
condition. 

There  is  intense  anemia  with  its  attending  phenomena. 
Pigment  granules  are  found  in  some  of  the  leukocytes  and 
in  the  plasma.  The  parasites  are  at  times  absent  from  the 
blood.  The  complexion  is  sallow  or  muddy.  The  tempera- 
ture is  usually  subnormal,  but  there  may  be  occasional 
slight  attacks  of  fever.  The  spleen  is  greatly  enlarged. 
Weakness  and  emaciation  are  marked.  Indigestion,  flatu- 
lency, and  constipation  are  common  symptoms.  Periodic 
headache,  neuralgia,  and  hematuria  are  sometimes  observed. 

Diagnosis  of  Malarial  Infection. — Estivo-autumnal 


MALARIAL   FEVER.  299 

fever  very  closely  resembles  typhoid  fever.  The  latter  may 
be  recognized  by  the  marked  abdominal  symptoms,  typical 
rash,  Widal  reaction,  and  the  absence  from  the  blood  of 
hematozoa. 

Yellow  Fever. — The  comparatively  slow  pulse,  early  albu- 
minuria, bloody  vomit,  single  remission  in  the  temperature, 
and  the  absence  of  splenic  enlargement  and  of  hematozoa 
from  the  blood  will  serve  to  distinguish  yellow  fever  from 
bilious  remittent  fever. 

Charcot's  Hepatic  Fever. — The  history  of  the  case,  the  pain 
and  tenderness  over  the  region  of  the  gall-bladder,  the  leuko- 
cytosis, and  the  absence  of  hematozoa  from  the  blood  will 
lead  to  the  recognition  of  this  condition. 

Leukemia. — The  marked  leukocytosis  and  the  presence  in 
the  blood  of  myelocytes  in  large  numbers  will  serve  to  sepa- 
rate myelogenous  leukemia  from  chronic  malarial  cachexia. 

Prognosis. — In  the  simple  intermitte?it  forms  of  malarial 
fever  the  prognosis  is  uniformly  favorable.  Recovery  usually 
follows  in  from  two  to  three  weeks.  Estivo-autiim,nal  fever 
is  more  resistant,  but  the  outlook  is  favorable.  Pernicious 
malarial  fever  is  an  exceedingly  grave  disease,  the  second  or 
third  paroxysm  not  infrequently  ending  fatally.  Many 
patients  with  chronic  malarial  cacJdexia  recover  under  appro- 
priate treatment,  but  when  the  spleen  is  extremely  large 
and  the  anemia  is  very  pronounced,  the  prognosis  must  be 
guarded. 

Treatment. — Prophylactic  measures  include  the  exter- 
mination of  mosquitos,  the  prevention  of  infection  of  mos- 
quitos,  and  the  prevention  of  infection  by  mosquitos  (Man- 
son).  The  most  useful  methods  of  suppressing  mosquitos 
are  the  efficient  drainage  of  pools  and  swamps  and  the  cul- 
tivation of  damp  soils.  Covering  the  surface  of  the  water 
with  petroleum  will  also  free  pools  from  larvas  for  from  two 
to  four  weeks.  To  prevent  the  infection  of  mosquitos,  ma- 
larial patients  should  be  carefully  screened.  The  chief 
means  of  preventing  infection  by  mosquitos  are  avoidance 
of  sleeping  in  the  open  air  and  of  exposure  to  the  evening 
and  early  morning  air,  adequate  protection  from  the  insects, 
and  the  use  of  quinin  in  daily  doses  of  from  2  to  5  grains. 


300  ACUTE  INFEC7T0US  DISEASES. 

Quinin  is  the  only  reliable  remedy  for  malarial  fever. 
Methylene-blue  (2  to  5  grains  with  half  its  weight  of  pow- 
dered nutmeg  thrice  daily)  and  Warburg's  tincture  possess 
some  value,  but,  being  distinctly  less  efficacious  than  quinin, 
they  should  be  employed  only  when  the  latter  is  not  well 
borne. 

In  ordinary  mtermittent  fever  the  quinin  should  be  given 
in  daily  doses  of  from  15  to  20  grains,  so  divided  that  the 
last  dose  is  taken  about  three  hours  before  the  expected 
chill. 

The  remedy  should  be  continued  in  full  doses  until  the 
paroxysms  fail  to  appear,  and  then  gradually  withdrawn 
over  a  period  of  several  weeks.  The  administration  of  a 
laxative  dose  of  calomel  as  a  preliminary  measure  increases 
the  efficacy  of  the  quinin,  probably  by  facilitating  its  absorp- 
tion. 

For  adults  quinin  is  best  prescribed  in  capsules,  cachets, 
or  freshly  made  pills.  For  children  it  may  be  given  sus- 
pended in  syrup  of  yerba  santa,  syrup  of  chocolate,  or 
elixir  of  licorice.  During  convalescence  iron  and  arsenic 
may  be  advantageously  given  with  the  quinin,  as  in  the  fol- 
lowing formula : 

U.     Ferri  pyrophosphatis gr.  xxx 

Arseni  trioxidi gr.  ss 

Quininse  sulphatis gi".  xl 

Pulveris  capsici  .........  gr.  x. — M. 

Pone  in  capsulas,  No.  xx. 

SiG. — One  thrice  daily  after  meals. 

In  estivo-autumnal  fever  larger  doses  of  quinin  (30  to  40 
grains  a  day)  are  usually  required.  In  pernicious  malarial 
fever  the  patient  should  be  cinchonized  as  quickly  as  possible 
by  injecting  at  once  into  the  tissues  of  the  thigh  or  buttock 
about  30-40  grains  of  a  soluble  salt  of  quinin  like  the  dihy- 
drochlorate. 

Symptomatic  Treatment. — During  the  cold  stage  of  the  par- 
oxysms the  patient  should  be  well  covered  with  warm 
blankets  and  given  hot  drinks.  Opium  in  the  form  of  pare- 
goric is  sometimes  useful  in  mitigating  discomfort.  It  may 
be  combined  with  a  few  minims  of  aromatic  spirits  of  ammo- 


SCARLET  FEVER.  3OI 

nia,  chloroform,  or  Hoffmann's  anodyne.  In  the  hot  stage 
much  relief  is  afforded  by  frequently  sponging  the  body  with 
cool  water,  giving  cold  drinks,  and  administering,  if  the 
symptoms  are  very  severe,  a  small  dose  of  phenacetin.  In  the 
algid  type  of  pernicious  malarial  fever  it  may  be  necessary  to 
give  alcohol  freely,  with  digitalis  and  strychnin,  to  tide  the 
patient  over  the  paroxysm. 

Malarial  cachexia  requires  tonic  and  hygienic  treatment. 
Arsenic,  iron,  and  cod-liver  oil  are  especially  valuable.  As 
in  other  manifestations  of  malaria,  quinin  is  indicated  so  long 
as  the  blood  shows  parasites.  According  to  Wood,  it  is 
much  better  to  produce  distinct  cinchonism  at  intervals  than 
to  give  the  drug  continuously  in  moderate  doses.  When 
there  is  constipation,  mild  bitter  laxatives  are  beneficial. 
Change  of  locality  is  sometimes  necessary  to  effect  a  cure. 

SCARLET  FEVER. 

(Scarlatina.) 

Definition. — An  acute,  contagious  disease,  characterized 
by  high  fever,  a  rapid  pulse,  a  punctiform  scarlet  rash,  sore 
throat,,  and  a  marked  tendency  to  nephritis. 

Ktiology. — The  specific  micro-organism  of  scarlet  fever 
has  not  been  isolated.  The  Streptococcus  pyogenes  is 
present  in  most  of  the  complicating  lesions.  The  contagium 
is  usually  carried  through  clothes  or  other  fomites,  or  in 
food,  particularly  milk.  The  poison  is  tenacious  and  of  ex- 
treme vitality ;  infected  clothes,  unused  for  years,  have  led 
to  outbreaks.  The  disease  is  probably  contagious  at  all 
periods,  but  it  is  most  so  during  the  stage  of  desquamation. 
The  young  are  especially  predisposed,  but  not  equally  so. 
One  attack  does  not  give  absolute  immunity,  but  second 
attacks  are  very  uncommon. 

Pathology. — The  throat  is  inflamed  and  sometimes  ulcer- 
ated ;  the  liver  and  spleen  are  engorged ;  and  the  muscles 
reveal  granular  degeneration.  The  kidneys  frequently  show 
the  lesions  of  hemorrhagic  nephritis,  the  glomeruli  being  es- 
pecially involved.     The  rash  is  rarely  detected  after  death. 

Varieties. — (i)  Simple;  (2)anginoid;  (3)  malignant. 


302  ACUTE   INFECTIOUS  DISEASES. 

Period  of  Incubation. — From  two  to  seven  days. 

Symptoms. — The  disease  generally  begins  suddenly,  oc- 
casionally with  a  chill,  but  more  commonly  with  vomiting  or 
convulsions. 

Throat  Symptoms. — These  consist  in  pain  and  difficulty  in 
swallowing ;  fullness  and  tenderness  beneath  the  jaw  ;  and  en- 
largement of  the  lymphatic  glands.  The  tongue  is  at  first 
heavily  coated  and  red  at  the  tip  and  edges  ;  in  a  few  days 
the  coating  almost  entirely  disappears,  and  the  papillae  be- 
come bright  red  and  swollen.  This  appearance  has  given 
rise  to  the  term  "  strawberry  tongue."  The  pillars,  tonsils, 
uvula,  and  pharyngeal  vault  are  deeply  injected  and  may 
reveal  a  punctiform  efflorescence  before  the  rash  develops  on 
the  skin.  In  severe  cases  the  tonsils  may  be  the  seat  of 
follicular  inflammation,  or  may  be  covered  with  false  mem- 
brane. 

Emption. — A  scarlet-red  punctiform  rash  appears  at  the' 
end  of  the  first  or  at  the  beginning  of  the  second  day,  on  the 
neck  and  chest,  and  rapidly  spreads  over  the  entire  body.  It 
disappears  on  pressure,  a  white  line  remaining  for  a  second 
or  two  when  the  finger-nail  is  drawn  through  it.  It  may  be 
uniform  or  it  may  occur  in  discrete  patches  surrounded  by 
healthy  skin.  The  rash  lasts  for  from  five  to  seven  days, 
and  is  followed  by  flaky  desquamation.  The  period  of  des- 
quamation may  last  for  from  two  to  six  weeks. 

In  some  cases  the  rash  is  pale  and  scarcely  visible,  in 
others  it  is  slightly  papular  or  vesicular  (scarlatina  miliaris)  ; 
in  malignant  cases  it  may  be  petechial. 

Febrile  Symptoms. — The  fever  rises  abruptly,  reaching  its 
maximum  (104°- 105°  F.)  in  from  twenty-four  to  forty-eight 
hours,  remains  nearly  uniform  for  three  or  four  days,  and 
then  falls  by  lysis.  The  duration  of  the  febrile  period  is 
from  seven  to  nine  days.  The  pulse  is  very  rapid — out  of 
proportion  to  the  fever ;  the  respirations  are  hurried ;  the 
appetite  is  lost;  the  bowels  are  constipated ;  and  the  urine 
is  scanty,  high-colored,  and  often  albuminous.  There  is  a 
well-marked  leukocytosis. 

Nervous  Symptoms. — Restlessness,  headache,  insomnia, 
delirium,  and  convulsions  may  occur  in  the  course  of  the 


\ 


SCARLET  FEVER.  303 

disease.  Convulsions  developing  late  in  the  disease  should 
suggest  uremia. 

Anginoid  Scarlet  Fever. — This  form  is  characterized  by 
severe  throat  symptoms.  The  tonsils  are  much  swollen  and 
are  often  covered  with  false  membrane.  The  fever  is  high 
and  the  prostration  is  profound.  Ulceration  of  the  throat 
frequently  occurs.  Death  may  result  from  exhaustion,  aspi- 
ration-pneumonia, or  hemorrhage. 

Malignant  Scarlet  Fever. — The  onset  is  abrupt,  with  a  chill, 
vomiting,  or  convulsion;  the  fever  is  very  high(io6°-i07°  F.)  ; 
the  pulse  is  rapid  and  feeble  ;  delirium  sets  in,  and  is  followed 
by  coma.  Death  may  result  before  the  appearance  of  the 
rash,  in  from  twenty-four  to  forty-eight  hours. 

Complications. — The  most  common  is  nephdtis.  This 
usually  develops  during  convalescence.  As  mild  attacks  are 
unassociated  with  constitutional  symptoms,  the  urine  should 
be  examined  daily.  Severe  attacks  are  manifested  by  sup- 
pression of  urine,  general  edema,  and  uremic  phenomena. 
Nephritis  may  be  the  immediate  cause  of  death  in  scarlet 
fever,  or  it  may  become  chronic.  Many  cases,  however,  end 
in  complete  recovery. 

Among  other  complications  may  be  mentioned  hyperpy- 
rexia, endocarditis,  pericarditis,  catarrhal  pneumonia,  sup- 
puration of  the  lymphatic  glands,  ophthalmia,  inflammation 
of  the  middle  ear,  and  a  peculiar  inflammation  of  the  joints 
resembling  rheumatism. 

Diagnosis. — Acute  tonsillitis  may  resemble  scarlet  fever, 
especially  when  the  former  is  associated  with  an  erythema- 
tous rash  ;  but  in  tonsillitis  there  is  no  history  of  contagion, 
the  pulse  is  proportionate  to  the  fever ;  the  rash,  if  present, 
is  not  punctiform  ;  the  tongue  has  not  the  strawberry  appear- 
ance ;  and  there  is  no  tendency  to  nephritis. 

Diphtheria. — The  onset  is  less  abrupt ;  there  is  more  pros- 
tration ;  false  membrane,  containing  the  Klebs-Loffler  ba- 
cillus, is  always  present ;  a  cutaneous  rash  is  usually  absent ; 
and  the  tongue  does  not  present  a  strawberry  appearance. 

Measles. — The  sore  throat  is  less  marked  ;  catarrhal  symp- 
toms are  present ;  the  rash  appears  later,  is  papular,  and 
forms  crescentic-shaped  patches ;  the  fever  shows  a  decided 


304  ACUTE  INFECTIOUS  DISEASES. 

remission  on  the  second  or  third  day ;  and  the  pulse  is  pro- 
portionate to  the  fever. 

Eotheln. — This  may  be  difficult  to  distinguish  from  scar- 
latina, but  the  fever  is  not  so  high,  nor  the  pulse  so  rapid ; 
the  postcervical  glands  are  more  swollen ;  there  is  no  ten- 
dency to  nephritis  ;  and  the  rash  is  not  punctiform. 

Accidental  Eashes. — Certain  drugs  like  belladonna,  quinin, 
and  copaiba,  and  certain  foods,  like  crabs  and  oysters,  may 
produce  a  rash  like  that  of  scarlet  fever,  but  it  is  not  puncti- 
form, and  is  not  associated  with  high  fever,  sore  throat,  and 
rapid  pulse. 

Prognosis. — Always  guarded.  The  mortality  varies  in 
different  epidemics  from  5  to  40  per  cent. 

Treatment. — The  patient  should  be  isolated  for  from 
six  to  eight  weeks.  All  articles  used  in  the  sick-room 
should  be  thoroughly  disinfected  before  being  removed. 
To  prevent  dissemination  of  the  scales  some  bland  ointment 
(cold  cream  or  cocoa-butter)  should  be  applied  to  the 
patient's  body  at  least  once  a  day  until  desquamation  is  com- 
plete. The  patient  should  not  be  allowed  to  leave  his  bed 
for  at  least  a  week  after  the  fever  has  subsided. 

The  diet  should  consist  of  milk,  junket,  kumiss,  ice- 
cream, fruit-juices,  and  gruels.  Water  should  be  given 
freely  to  relieve  thirst  and  to  keep  the  secretions  active. 

Vomiti?tg  will  call  for  antiemetics — cracked  ice,  carbonated 
water,  bismuth  subnitrate,  or  diluted  hydrocyanic  acid. 

Fever. — Tepid  sponging  is  very  grateful  throughout  the 
febrile  period.  Fever  above  103°  F.  should  be  combated 
with  cold  packs  or  baths  (80°  F.),  and  by  cold  applications 
to  the  head. 

When  the  temperature  is  not  very  high,  a  mild  febrifuge 
like  the  following  will  be  found  useful : 

R-     Spiritus  getheris  nitrosi ^"^v] 

Liquor  ammonii  acetatis  .    .    .     q.  s.  ad  f^iij. — M. 
SiG. — Dessertspoonful  with  water  every  three  hours  for  a  child  of 
five  years. 

Throat  Symptoms. — The  nose  and  throat  should  be 
cleansed  with  mild  antiseptic  sprays,  such  as  a  weak 
Dobell's  solution  or  a  solution  of  hydrogen  dioxid  (i  :  4). 


MEASLES.  305 

When  tonsillitis  is  severe,  the  following  application  will  be 
found  efficacious : 

R.     Potassii  chloratis gr.  xx 

Tincturse  ferri  chloridi 

Glycerini aaf5ss 

Aquae q.  s.  ad  £5!]. — M. 

SiG. — Apply  to  the  tonsils  several  times  a  day  with  a  cotton  swab. 

Cardiac  weakness  must  be  combated  with  such  drugs  as 
alcohol,  strychnin,  and  digitalis. 

Cerebral  symptoms  are  best  controlled  by  the  application 
of  an  ice-cap  and  the  administration  of  bromids  or  small 
doses  of  chloral  or  phenacetin.  When  the  nervous  symp- 
toms are  due  to  high  temperature,  cold  bathing  is  most 
effective. 

In  acute  otitis  media  nothing  affords  so  much  relief  as 
gently  syringing  the  auditory  canal  with  hot  water.  The 
apphcation  of  a  leech  behind  the  ear  is  also  useful.  When 
the  tympanic  membrane  bulges,  indicating  the  presence  of 
pent-up  pus,  the  latter  should  be  evacuated  by  puncture. 

Should  severe  nephritis  develop,  dry  cupping  over  the 
loins,  followed  by  warm  fomentations,  will  often  prove  of 
value.  Aperients,  especially  sahnes,  are  indicated.  Warm 
baths,  hot  packs,  vapor-baths,  or  pilocarpin  (ylg-  to  -^-^  grain) 
should  be  used  to  promote  diaphoresis.  When  the  urine  is 
scanty,  unirritating  diuretics,  like  potassium  acetate  or  bi- 
tartrate  and  digitalis,  are  of  service. 

MEASLES* 

(Rubeola;  Morbilli.) 

Definition. — An  acute  contagious  disease,  characterized 
by  catarrh  of  the  respiratory  tract,  moderate  fever,  and  a  red 
papular  eruption,  which  appears  on  the  fourth  day,  lasts 
four  or  five  days,  and  is  followed  by  bran-like  desquamation. 

!^tiologfy. — Measles  is  highly  contagious,  and  the  poison 
may  be  transmitted  through  clothes  and  other  fomites.    The' 
contagium  is  apparently  associated  with  the  nasal  and  bron- 
chial secretion,  but  it  has  not  been  isolated.    Measles  is  most 
commonly  observed  in  children,  but  unprotected  adults  are 

20 


3o6  ACUTE  INFECTIOUS  DISEASES. 

very  liable  to  be  attacked.  It  is  essentially  an  epidemic  dis- 
ease, but  now  and  then  sporadic  cases  occur.  One  attack 
usually  confers  immunity  against  subsequent  attacks. 

Patllolog"y. — The  lesions  consist  in  catarrh  of  the  entire 
respiratory  tract.  Gastro-intestinal  catarrh  is  not  uncom- 
mon. In  fatal  cases  such  complications  as  catarrhal  pneu- 
monia and  pulmonary  collapse  are  frequently  observed. 

Period  of  Incubation. — Ten  days  to  two  weeks. 

Symptoms. — The  invasion  is  characterized  by  catan4ial 
symptoms — photophobia,  redness  of  the  eyes,  increased  lacri- 
mation,  sneezing,  discharge  from  the  nose,  hoarseness,  cough, 
and,  in  older  children,  expectoration. 

The  Fever. — The  temperature  rises  rapidly  to  103°  or 
104°  F.,  but  on  the  second  day  there  is  often  a  decided  re- 
mission which  continues  until  the  fourth  day,  when  the 
eruption  appears ;  at  this  time  it  again  rapidly  runs  up  to 
or  beyond  its  original  height,  where  it  remains  for  three  or 
four  days  and  then  falls  by  rapid  lysis  or  crisis. 

The  Eruption. — This  appears  about  the  third  or  fourth 
day  on  the  face,  and  rapidly  spreads  over  the  entire  body. 
It  is  composed  of  small,  dark-red,  velvety  papules,  which 
form  groups  having  crescentic  borders.  There  are  often 
much  burning  and  itching  of  the  skin.  In  three  or  four 
days  the  eruption  begins  to  fade,  and  a  branny  desquama- 
tion soon  follows. 

Minute  bluish-white  specks  surrounded  by  a  red  areola 
may  be  seen  on  the  mucous  membrane  of  the  cheeks  and 
lips  one  or  two  days  before  the  skin  eruption  appears  (Kop- 
lik's  sign). 

Malignant  or  Hemorrhagic  Measles. — This  form  occurs 
under  bad  hygienic  conditions,  and  is  characterized  by  a 
petechial  rash,  by  hemorrhages  from  the  mucous  mem- 
branes, and  by  profound  prostration. 

Complications  and  Sequelae. — Bronchopneumonia 
and  acute  gastro-intestinal  catarrh  are  the  most  common 
complications.  Among  the  less  frequent  complications  or 
sequelae  may  be  mentioned  membranous  or  ulcerative 
laryngitis,  otitis,  chronic  conjunctivitis,  pulmonary  tubercu- 
losis, cancrum  oris,  and  neuritis. 


MEASLES.  307 

Diagnosis. — Rotheln. — Prodromes  are  often  absent ; 
fever  and  catarrh  are  slight ;  sore  throat  is  marked.  The 
rash  appears  on  the  first  or  second  day  as  a  diffuse  red 
blush,  or  as  small,  pale-red  spots  that  do  not  form  cres- 
centic-shaped  patches  ;  desquamation  is  scarcely  noticeable. 

Scarlet  Fever. — The  onset  is  more  sudden  and  is  marked 
by  vomiting  ;  there  is  severe  sore  throat  instead  of  a  general 
catarrh  ;  Koplik's  sign  is  absent,  but  the  tongue  is  charac- 
teristic ;  the  rash  appears  on  the  first  or  second  day  as  a 
diffuse  punctiform  erythema ;  the  pulse  is  out  of  proportion 
to  the  fever,  and  there  is  much  greater  tendency  to  nephritis. 

Prognosis. — Guardedly  favorable.  Complications  are 
liable  to  occur  and  render  the  prognosis  grave. 

Treatment. — The  child  should  be  quarantined  for  at 
least  four  weeks  from  the  onset  of  the  disease.  The  sick- 
room should  be  well  ventilated  and  moderately  darkened. 
At  least  two  weeks  should  be  spent  in  bed. 

Milk,  junket,  fruit-juices,  broths,  eggs,  and  gruels  are 
suitable  forms  of  nourishment.  Water  should  be  proffered 
at  frequent  intervals. 

Daily  inunctions  of  the  body  with  cold  cream  or  cocoa- 
butter  will  serve  to  allay  burning  and  itching  of  the  skin. 
When  conjunctivitis  is  marked,  the  eyes  should  be  protected 
with  dark  glasses  and  frequently  cleansed  with  a  solution 
of  boric  acid  (15  grains  to  the  ounce).  Hot  baths  and  hot 
drinks  are  indicated  when  the  rash  is  delayed. 

High  temperature  is  best  controlled  by  cold  sponging  or 
cold  packs.  Diarrhea  will  call  for  bismuth  subnitrate  and 
antiseptics  Hke  salol  or  bismuth-beta-naphthol.  When  there 
is  severe  bronchial  catarrh,  expectorants  with  sedatives,  like 
paregoric,  are  indicated.  The  following  mixture  will  be 
found  useful : 

Ijt.     Potassii  citratis ^'J 

Tincturae  opii  camphoratse ,  fj^ij-iv 

Glycerini f^j 

Aqus q.  s.  ad  fjiij. — M. 

SiG. — A  teaspoonful  every  two  hours  for  a  child  of  three  years. 

During  convalescence  tonics — iron,  strychnin,  and  cod- 
liver  oil — are  indicated. 


308  ACUTE   INFECTIOUS  DISEASES, 

RUBELLA. 

(Rdtheln;  German  Measles;  Epidemic  Roseola.) 

Definition. — An  acute  contagious  disease  resembling 
both  scarlet  fever  and  measles,  but  differing  from  these  in 
its  short  course,  slight  fever,  and  freedom  from  sequelae. 

]^tiolog"y. — The  disease  is  highly  contagious,  and  the 
poison  may  be  carried  on  clothes  or  other  fomites.  It  gen- 
erally occurs  in  epidemics,  but  sporadic  cases  are  not  uncom- 
mon. It  is  most  frequently  observed  in  children,  but  un- 
protected adults  are  not  exempt.  One  attack  usually 
protects  from  another,  but  not  from  measles  or  scarlet  fever. 

Period  of  Incubation. — One  to  three  weeks. 

Symptoms. — Prodromes  are  slight  or  altogether  absent. 
The  disease  begins  with  drowsiness,  slight  fever,  and  sore 
throat.  The  eruption  appears  on  the  first  or  second  day, 
and  varies  considerably  in  its  character.  In  some  cases  the 
rash  is  composed  of  pale-red,  scarcely  elevated  papules, 
which  are  more  or  less  discrete  {I'ubella  morbilliforme) ;  in 
others  the  rash  is  bright  red  and  diffuse,  like  that  of  scarlet 
fever  {nibella  scarlatinifoinne).  It  begins  on  the  face  and 
rapidly  spreads  over  the  entire  body,  but  it  fades  so  rapidly 
that  the  face  may  be  clear  before  the  extremities  are  affected. 
Slight  desquamation  frequently  follows,  though  it  is  often 
absent.  Apart  from  the  sore  throat,  the  catarrhal  symptoms 
are  slight.  A  very  constant  and  somewhat  characteristic 
feature  is  marked  swelling  of  the  postcervical  glands. 

The  duration  is  from  three  to  five  days. 

Prognosis. — Good.     Complications  are  very  rare. 

Treatment  is  that  of  measles. 

SMALLPOX. 

(Variola.) 

Definition. — An  acute  contagious  disease  characterized 
by  vomiting ;  lumbar  pains  ;  an  eruption  which  is  at  first 
papular,  then  vesicular,  and  finally  pustular;  and  by  fever 
which  is  marked  by  a  distinct  remission,  beginning  with  the 
advent  of  the  eruption  and  lasting  until  the  latter  becomes 
pustular. 


SMALLPOX.  309 

etiology. — The  poison  of  smallpox  is  extremely  tena- 
cious :  it  may  remain  latent  in  clothes  or  other  fomites  for  a 
long  time,  and  then  be  capable  of  exciting  the  disease. 
Unless  protected  by  vaccination  or  a  previous  attack,  nearly 
everyone,  from  the  child  /;/  ittero  to  the  aged,  is  susceptible 
to  the  contagion.  The  colored  race  seems  to  be  especially 
predisposed. 

Certain  protozoa — Cytorrhyctes  vaiiolcE — which  are  invari- 
ably found  in  the  cells  of  the  vesicles  and  which  present  them- 
selves in  two  forms — one  cytoplasmic  and  the  other  an  intra- 
nuclear form — appear  to  be  the  specific  cause  of  the  disease. 

Pathology. — The  development  of  the  variolous  vesicle 
is  the  result  of  a  peculiar  degeneration  of  the  protoplasm 
of  the  epithelial  cells  of  the   rete   mucosum.     There  is  a 


Fig.  17. — Temperature-curve  in  smallpox. 

reticular  degeneration  of  the  cytoplasm  with  a  more 
advanced  degeneration  of  the  nucleus.  Genuine  pocks  are 
frequently  found  in  the  mouth,  esophagus,  nose,  and  larynx. 
Even  the  trachea  and  bronchi  may  contain  them.  The 
spleen  is  engorged.  The  organs  and  muscles  reveal  fatty 
and  parenchymatous  degeneration. 

Varieties. — Discrete  ;  confluent ;  malignant ;  varioloid. 

Period  of  Incubation. — Ten  days  to  two  weeks. 

Symptoms. — Discrete  Smallpox. — The  disease  usually 
begins  with  a  chill  or  series  of  chills,  followed  by  vomiting 
and  intense  lumbar  pains.  The  fever  rises  rapidly,  reaching 
its  maximum  (i 04^-105°  F.)  in  forty-eight  hours,  and  con= 
tinues  high  until  the  third  or  fourth  day,  when  it  falls  sev= 
eral  degrees  ;  this  remission  lasts  until  the  seventh  or  eighth 
day — that  is,  until  the  time  of  pustulation — when  the  tem- 


310  ACUTE   INFECTIOUS  DISEASES. 

perature  again  rises.  The  secondary  or  suppurative  fever 
shows  marked  fluctuations  ;  its  height  is  proportionate  to 
the  number  of  pustules  ;  and  it  falls  by  lysis  about  the 
eighteenth  day  of  the  disease.  The  pulse  is  full  and  rapid 
(120-140);  the  breathing  is  hurried;  the  skin  is  dry;  the 
bowels  are  usually  constipated,  though  diarrhea  is  not 
uncommon ;  and  the  urine  is  scanty  and  frequently  albu- 
minous. 

The  Eruption. — About  the  third  or  fourth  day  small  red 
spots  are  noticed  on  the  forehead,  face,  and  wrists ;  these  are 
rapidly  converted  into  smooth,  round  papules  that  feel  like 
shot  under  the  skin.  The  eruption  rapidly  spreads  over  the 
entire'  body.  About  the  third  day  the  papules  are  con- 
verted into  clear  vesicles,  which  present  a  depression  or 
umbiHcation  at  their  summit.  They  are  also  loculated, — 
i.  e.,  divided  into  compartments  by  fibrinous  partitions, — so 
that  when  pricked  with  a  needle  all  the  contained  fluid  does 
not  escape.  In  two  or  three  days  the  clear  fluid  becomes 
turbid  and  the  vesicles  are  gradually  converted  into  pus- 
tules. The  latter  soon  lose  the  umbilicated  appearance. 
Between  the  lesions  the  skin  is  edematous,  so  that  the  body 
is  swollen  and  the  features  are  unrecognizable.  In  three  days 
more  the  pustules  dry  up,  or  break  and  form  soft  yellow 
crusts  that  exhale  a  peculiar,  offensive  odor ;  they  adhere  to 
the  skin  for  a  week  or  more.  When  the  scabs  fall  off,  scars 
or  pock-marks  generally  remain,  constituting  a  permanent 
deformity. 

At  the  beginning  of  the  disease,  before  the  true  variolous 
eruption  appears,  either  a  red  blush  or  a  macular  rash  is 
often  observed  on  the  inner  side  of  the  arms  and  thighs. 

Confluent  Smallpox. — The  papules  are  abundant  and  soon 
coalesce.  The  extremities  are  swollen  and  painful.  The 
secondary  fever  is  very  high  and  irregular.  True  pocks 
nearly  always  develop  in  the  air-passages  and  give  rise  to  a 
copious  fetid  discharge  from  the  nose  and  throat,  to  hoarse- 
ness, and  to  cough.  Delirium,  stupor,  and  subsultus  are 
frequent  symptoms.  If  the  patient  recovers,  it  is  after  a 
tedious  convalescence,  with  great  facial  disfigurement,  and 
often  with  defective  vision  or  hearing. 


SMALLPOX.  311 

Malignant  Smallpox. — In  some  cases  the  disease  is  ushered 
in  with  high  fever,  lumbar  pains,  and  great  prostration. 
Soon  ecchymoses  appear  on  the  skin ;  bleeding  from  the 
mucous  membranes  follows ;  and  death  results  before  a  true 
variolous  rash  appears.  In  other  cases  the  disease  advances 
like  ordinary  smallpox  up  to  the  pustular  stage  ;  then  the 
pustules  become  effused  with  blood,  and  bleeding  from 
the  mucous  membranes  follows.  This  form  is  also  very 
fatal. 

Varioloid. — This  is  modified  smallpox  occurring  in  one  who 
has  been  partially  protected  by  previous  vaccination.  The 
symptoms  are  mild ;  the  eruption  resembles  that  of  common 
smallpox,  but  it  is  usually  scant  and  of  short  duration ;  sec- 
ondary fever  is  absent. 

Complications  and  Sequelae. — The  most  common  are 
bronchopneumonia ;  pleurisy ;  inflammations  of  the  eye 
(ulcerative  keratitis,  iritis,  conjunctivitis);  otitis;  ulcerative 
laryngitis  ;  arthritis  ;  and  furuncles. 

Diagnosis. — Varicella. — In  this  disease  prodromes  are 
generally  absent  and  the  constitutional  symptoms  are  mild. 
The  eruption  appears  on  the  first  day ;  it  comes  out  in  suc- 
cessive crops;  and,  unlike  that  of  smallpox,  prefers  the 
covered  surfaces.  It  may  be  maculopapular  at  first,  but  it 
becomes  vesicular  within  a  few  hours.  The  lesions  are 
superficial ;  vary  greatly  in  size ;  are  usually  unilocular,  and 
are  rarely  umbilicated.  Desiccation  begins  in  two  or  three 
days,  the  vesicles  becoming  irregularly  puckered  at  the 
periphery  and  presenting  a  depressed  blackish  crust  in  the 
center — a  highly  characteristic  appearance.  In  doubtful 
cases  in  children  the  presence  of  a  typical  vaccinal  cicatrix 
constitutes  strong  presumptive  evidence  against  variola. 

Syphilis. — The  history  of  infection  ;  the  associated  evi- 
dences of  syphilis  (mucous  patches,  alopecia,  etc.) ;  the 
gradual  onset  of  the  illness;  the  sHght  fever;  the  symmetric 
distribution  of  the  eruption  ;  its  dark  coppery  color ;  its 
polymorphous  character  (papules,  vesicles,  and  pustules 
associated  in  a  limited  area) ;  and  the  absence  of  itching  will 
indicate  syphilis. 

Prognosis. — This   depends   upon   the  virulence   of  the 


312  ACUTE   INFECTIOUS  DISEASES. 

epidemic,  the  vaccinal  condition  of  the  patient,  and  the 
amount  of  eruption.  In  the  discrete  cases  the  prognosis  is 
generally  favorable ;  in  the  confluent,  very  grave ;  and  in 
the  malignant,  almost  hopeless.  In  the  unvaccinated  the 
mortality  ranges  between  20  and  60  per  cent.  Among  those 
having  one  or  two  typical  vaccine  scars,  the  death-rate  is 
very  low — usually  less  than  3  per  cent. 

Treatment. — The  preventive  measures  against  smallpox 
include  the  complete  isolation  of  the  patient  (preferably  in  a 
special  hospital),  the  thorough  disinfection  of  all  objects  that 
have  been  in  contact  with  him,  and,  above  all,  the  vaccina- 
tion of  all  who  have  been  or  who  are  likely  to  be  exposed 
to  the  contagion.  Absolute  rest  in  bed,  light  bed-clothing, 
a  well-ventilated  room  of  a  temperature  of  65°  F.,  an  easily 
assimilable  but  sustaining  diet,  and  the  free  use  of  cool 
drinks  are  requisites  of  treatment.  The  severe  lumbar 
pains  will  require  opium  and  the  application  of  hot-water 
bags.  Fever  is  best  combated  by  hydrotherapy— cold 
sponging,  cold  packs,  or  cold  baths.  Antipyretic  drugs 
should  be  used  with  caution. 

Gastric  irritability  may  be  controlled  by  diluted  hydrocyanic 
acid  (2  minims),  subnitrate  of  bismuth  (10  grains),  or  cocain 
(i  grain).  When  nervous  symptoms  are  not  relieved  by 
hydrotherapy,  opium  with  bromids  or  chloral  with  bromids 
should  be  tried.  Alcoholic  stimulants  are  frequently  de- 
manded, especially  in  confluent  cases. 

An  attempt  should  be  made  to  keep  the  nasopharynx 
clean  by  means  of  antiseptic  sprays  or  douches.  The  eyes 
should  also  be  kept  clean  by  frequent  applications  of  a  warm 
boric-acid  solution  (15  grains  to  the  ounce). 

Prevention  of  Pitting. — The  room  should  be  darkened 
and  the  exposed  parts  covered  with  cloths  wrung  out  of  a 
weak  solution  of  carboHc  acid  (i  :  200)  or  of  corrosive  sub- 
limate (i  :  5000  or  I  :  10,000).  Unfortunately,  when  the 
lesions  are  deeply  seated,  there  are  no  efficient  means  of 
preventing  pitting. 

In  the  stage  of  desiccation,  warm  baths  followed  by  in- 
unctions with  cold  cream  or  olive  oil  are  useful  in  allaying 
itching  and  in  hastening  the  removal  of  the  crusts. 


VACCINIA.  313 

VACCINIA* 
(Vaccination ;  Cow-pox.) 

Definition. — A  general  disease  with  a  local  manifestation 
resembling  the  pock  of  variola,  and  acquired  by  inoculation 
with  the  virus  of  cow-pox. 

History  and  Object. — The  value  of  vaccination  as  a 
means  of  protection  against  smallpox  was  first  made  known 
to  the  world  in  a  paper  published  by  Edward  Jenner  in  1798. 

Recent  vaccination  gives  almost  complete  immunity  against 
variola ;  the  mortality  of  smallpox  acquired  after  vaccina- 
tion is  almost  inversely  proportionate  to  the  number  of  true 
vaccine  scars. 

Ktiology. — Vaccinia  is  induced  by  inoculating  the  arm 
or  leg  with  fresh  virus  obtained  from  the  udder  of  a  calf 
suffering  from  cow-pox  (bovine  virus).  Formerly  virus 
taken  from  a  human  vaccine  vesicle  was  also  employed 
(humanized  virus),  but  on  account  of  the  risk  of  transmit- 
ting syphilis  and  other  diseases,  this  source  has  been  prac- 
tically abandoned. 

It  has  been  shown  that  the  addition  of  glycerin  to  vaccine 
lymph  serves  to  preserve  it  and  to  free  it  from  pathogenic 
bacteria. 

Time  of  Performance. — The  first  vaccination  should  be 
performed,  as  a  rule,  about  the  second  or  third  month,  the 
second  at  the  seventh  year,  and  the  third  at  puberty.  Vac- 
cination should  always  be  repeated  when  smallpox  is  preva- 
lent. 

Performance  of  Vaccination. — The  part  selected 
should  be  thoroughly  cleaned  with  soap  and  water,  then 
with  alcohol,  and  finally  with  pure  water.  A  number  of 
cross-scratches  should  next  be  made  over  an.  area  about 
\  of  an  inch  in  diameter,  with  a  sterilized  needle  or  special 
scarificator,  deep  enough  to  allow  of  a  little  oozing  of  pink- 
ish serum.  The  virus  should  then  be  applied  and  well  rubbed 
into  the  exposed  lymph-spaces  by  additional  scarification.  A 
shield  may  be  worn  for  a  few  hours  until  the  wound  has 
become  perfectly  dry  ;  after  that  it  should  be  discarded. 

Symptoms. — About  the   third   or  fourth  day  after  the 


314  ACUTE  INFECTIOUS  DISEASES. 

Operation  a  papule  surrounded  by  a  red  areola  forms  at 
the  seat  of  inoculation.  In  two  or  three  days  the  papule 
becomes  transformed  into  a  clear  vesicle  with  a  central  de- 
pression. The  tissues  surrounding  the  vesicle  are  red,  infil- 
trated, and  tender,  and  the  seat  of  intense  itching.  The 
vesicle  reaches  its  full  size  by  the  eighth  or  ninth  day, 
when  it  ruptures  and  discharges  or  dries  to  a  crust.  The 
latter  remains  for  from  one  to  three  weeks,  when  it  falls  off, 
leaving  a  red  cicatrix  that  later  becomes  white  and  pitted. 

During  the  course  of  the  eruption  there  may  be  slight 
fever,  malaise,  restlessness,  and  enlargement  of  the  axillary 
glands. 

Complications. — Abscess  or  erysipelas  may  result  from 
secondary  infection.  Various  generalized  eruptions,  such 
as  urticaria  or  erythema  multiforme,  are  occasionally  excited 
by  vaccination.     Tetanus  has  occurred  in  a  few  instances. 

VARICELLA. 

(Chicken-pox.) 

Definition. — An  acute  contagious  disease  of  short  dura- 
tion, characterized  by  slight  fever  and  a  discrete  vesicular 
eruption,  which  disappears  in  two  or  three  days  by 
desiccation. 

etiology. — The  disease  occurs  sporadically  and  epidemi- 
cally. It  is  observed  chiefly  in  children,  but  adults  are  not 
exempt.  One  attack  usually  protects  from  others.  It  bears 
no  relation  to  smallpox. 

Period  of  Incubation. — Fourteen  to  sixteen  days. 

Symptoms. — In  most  cases  there  is  slight  fever, —  ioo°- 
102°  F., — with  chilliness  and  malaise.  Not  infrequently, 
however,  constitutional  symptoms  are  wholly  wanting. 

Eruption. — This  appears  within  the  first  twenty-four  hours. 
At  first  it  is  maculopapular,  but  within  a  few  hours  it  be- 
comes vesicular.  The  vesicles  are  usually  sparse ;  are  most 
abundant  upon  the  trunk ;  come  out  in  crops ;  are  super- 
ficial and  very  variable  in  size ;  are  unilocular ;  and  are 
rarely  umbilicated.  In  two  or  three  days  desiccation  begins, 
the  vesicles  becoming  irregularly  puckered  at  the  periphery 


DIPHTHERIA.  3 1 5 

and  presenting  a  depressed  blackish  crust  in  the  center. 
The  crusts  are  thin  and  friable.  In  the  majority  of  cases 
there  is  no  marking,  but  occasionally  a  few  scars  or  pits 
remain. 

In  rare  instances  gangrene  occurs  around  the  vesicles  or 
in  other  parts  {I'aricella  gangrcenosci). 

Diagnosis. — The  differential  diagnosis  between  varicella 
and  smallpox  has  already  been  considered  (see  p.  31 1). 

Prognosis. — This  is  always  favorable.  Complications 
are  very  rare. 

Treatment. — No  special  treatment  is  required.  The 
child  should  be  separated  from  others  until  the  crusts  have 
disappeared.  Itching  may  be  allayed  by  applications  of 
carbolized  vaselin. 

DIPHTHERIA* 

Definition. — An  acute  contagious  disease  excited  by  the 
Klebs-Loffler  bacillus,  and  characterized  by  moderate  fever, 
glandular  enlargement,  great  prostration,  anemia,  and  the 
formation  of  a  false  membrane  upon  certain  mucous  mem- 
branes, especially  those  of  the  throat  and  adjacent  parts. 

etiology. — Three-fourths  of  the  cases  occur  in  chil- 
dren before  the  tenth  year.  Damp,  cold  weather  and  bad 
hygienic  surroundings  favor  outbreaks  of  the  disease. 

Chronic  catarrhal  affections  of  the  nose  and  throat  dis- 
tinctly increase  the  susceptibility  to  infection.  The  immu- 
nity afforded  by  one  attack  is  of  short  duration. 

The  exciting  cause  is  the  Klebs-Loffler  bacillus, — the 
Bacillus  diphtheriae, — which  is  found  chiefly  in  the  affected 
mucous  membranes,  and  only  exceptionally  in  the  blood 
and  in  distant  organs.  The  constitutional  symptoms  are 
caused  by  the  absorption  of  toxins  produced  by  the  bacillus. 

Pathology. — The  false  membrane  is  usually  found  on 
the  tonsils,  pillars,  and  pharynx,  but  it  may  extend  to  the 
mouth,  larynx,  or  nose.  The  bacillus  coming  in  contact 
with  the  mucous  membrane  causes  a  coagulation-necrosis 
of  the  superficial  cells  and  an  inflammatory  exudation,  the 
whole  constituting  the  false  membrane.  The  latter  usually 
has  a  grayish  or  yellowish  appearance,  is  firmly  attached  to 


3l6  ACUTE  INFECTIOUS  DISEASES. _ 

the  underlying  tissues,  and  when  forcibly  removed,  leaves  a 
raw  and  bleeding  surface.  Microscopically,  it  is  composed 
of  fibrin,  epithelial  cells,  and  leukocytes  (more  or  less 
degenerated),  Klebs-Loffler  bacilli,  and  pyogenic  cocci. 

The  lymphatic  glands  near  the  seat  of  infection  are 
swollen.  Focal  necrosis,  due  to  the  action  of  the  toxin,  is 
found  in  the  liver  and  other  organs.  The  heart,  kidneys, 
and  liver  are  the  seat  of  fatty  and  parenchymatous  degenera- 
tion. Interstitial  hemorrhages  are  frequently  observed  and 
are  the  result  of  hyaline  degeneration  of  the  capillary  walls 
and  thrombotic  obstruction.  Such  lesions  as  congestion, 
edema,  bronchopneumonia,  and  atelectasis  are  frequently 
encountered  in  the  lungs. 

Types. — Diphtheria  may  be  divided  according  to  the  loca- 
tion of  the  exudate  into  :  (i)  Faucial  ;  (2)  laryngeal;  and  (3) 
nasal.  According  to  the  severity  of  the  attack  it  may  be 
divided  into  :  (i)  Mild  ;  (2)  grave  ;  (3)  malignant. 

Period  of  Incubation. — Two  days  to  a  week. 

Symptoms. — Faucial  Diphtheria. — The  disease  commonly 
begins  with  chills,  moderate  fever,  malaise,  and  sore  throat. 
The  fever,  as  a  rule,  is  not  very  high  (102°- 104°  F.),  and 
its  course  is  quite  irregular.  The  pulse  is  rapid  and  feeble ; 
the  bowels  are  constipated ;  the  urine  is  scanty  and  fre- 
quently albuminous  ;  and  the  prostration  and  pallor  are 
often  out  of  all  proportion  to  the  severity  of  the  febrile 
symptoms. 

Local  Pheno7nena. — The  child  complains  of  difficult 
swallowing  ;  the  muscles  of  the  neck  feel  stiff;  there  is 
tenderness  under  the  jaw ;  the  lymphatic  glands  are  con- 
siderably swollen  ;  and  the  tonsils,  faucial  pillars,  uvula,  and 
posterior  pharyngeal  wall  are  covered  with  a  grayish-white 
membrane  which,  when  stripped  off,  exposes  a  raw  bleeding 
surface.     The  membrane  may  spread  to  the  nose  or  larynx. 

The  course  of  the  disease  is  indefinite,  but  the  average 
duration  is  from  one  to  two  weeks. 

Laryngeal  Diphtheria. — This  is  usually  secondary  by  ex- 
tension from  the  fauces,  but  it  is  occasionally  primary.  It  is 
recognized  by  hoarseness  or  aphonia,  croupy  cough,  pro- 
gressive dyspnea,  and  stridulous  breathing.     The  alae  of  the 


DIPHTHERIA.  3 1  / 

nose  play;  the  sternocleidomastoids  are  prominent;  the 
suprasternal  notch  is  deepened ;  and  the  base  of  the  chest  is 
retracted.  Shreds  of  false  membrane  are  sometimes  expec- 
torated in  the  violent  fits  of  coughing.  The  pulse  is  rapid 
and  feeble,  but  the  temperature  is  rarely  high.  Death  often 
results  from  suffocation,  but  recovery  is  not  impossible  even 
in  the  most  unpromising  cases. 

Nasal  Diphtheria. — This  is  usually  secondary.  It  is  char- 
acterized by  grave  constitutional  symptoms — high  fever, 
marked  glandular  involvement,  and  great  prostration ;  by  an 
offensive  discharge  from  the  nose ;  by  epistaxis  ;  and  by  ex- 
coriation of  the  lips.  The  false  membrane  may  be  detected 
on  inspection. 

Complications  and  Sequelae. — The  most  common 
complications  are  heart  failure  from  myocarditis  or  neuritis 
of  the  cardiac  nerves,  bronchopneumonia,  acute  nephritis, 
hemorrhage  from,  the  ulcerated  surfaces,  and  otitis  media. 
The  most  important  sequel  is  postdiphtJieric  paralysis. 
This  generally  occurs  during  convalescence,  and  is  observed 
in  about  15  per  cent,  of  all  cases.  There  is  no  relation 
between  the  severity  of  the  attack  of  diphtheria  and 
the  liability  to  paralysis  ;  mild  cases,  which  are  thought 
to  be  simple  pharyngitis,  being  sometimes  followed  by 
troublesome  paralysis.  The  pharynx  is  the  most  com- 
mon seat,  and  the  palsy  is  recognized  by  difficult  swallow- 
ing and  the  regurgitation  of  liquids  through  the  nose.  Next 
in  frequency  the  eyes  are  involved,  and  strabismus  or  ptosis 
develops.  The  heart  may  be  affected,  and  if  sudden  death 
does  not  result,  the  condition  may  be  manifested  by  tachy- 
cardia or  bradycardia.  In  some  instances  there  is  an  exten- 
sive involvement  of  the  extremities.  The  paralysis  is  due  to 
toxic  neuritis. 

Diagnosis. — Scarlet  Fever. — This  can  be  distinguished  by 
the  characteristic  strawberry  tongue,  the  very  rapid  pulse, 
the  diffuse  punctiform  rash,  and  the  absence  of  the  diphtheria 
bacillus. 

Follicular  Tonsillitis. — The  differential  diagnosis  between 
this  disease  and  diphtheria  has  already  been  considered 
(seep.  32). 


3l8  ACUTE  INFECTIOUS  DISEASES. 

Prognosis. — This  must  always  be  guarded.  The  disease 
is  very  fatal  during  the  first  two  years  of  life.  The  average 
mortality  at  the  present  time  ranges  between  1 5  and  20  per 
cent.  The  nasal  and  laryngeal  forms  are  always  grave. 
Death  may  be  due  to  exhaustion  from  the  toxemia,  involve- 
ment of  the  larynx,  bronchopneumonia,  cardiac  paralysis,  or 
nephritis. 

Treatment. — Prophylaxis. — As  diphtheria  is  prone  to  at- 
tack unhealthy  mucous  membranes,  nasopharyngeal  catarrh 
in  children  should  receive  careful  attention.  Large  tonsils 
and  adenoid  growths  should  be  removed.  Those  who  have 
been  exposed  to  the  contagion  should  receive  immunizing 
doses  of  antitoxin  (500  units).  Patients  with  diphtheria 
should  be  kept  isolated  until  their  throats  are  free  from  vir- 
ulent bacilli.  The  bedroom,  bedding,  clothing,  and  all 
utensils  used  by  the  sick  should  be  thoroughly  disinfected. 

Treatment  of  the  Attack. — The  sick-room  should  be  well 
ventilated,  and  the  temperature  maintained  at  about  70°  F. 
It  is  desirable  to  have  the  atmosphere  moist,  and  this  may 
be  accomplished  by  generating  steam  in  an  ordinary  kettle 
or  in  a  steam  atomizer,  or  by  slaking  large  quantities  of 
quicklime  in  the  room.  Young  children,  especially  when 
laryngeal  symptoms  are  present,  are  best  treated  in  a  steam- 
moistened  tent.  Absolute  rest  must  be  enforced.  The  diet 
should  be  of  the  most  nutritious  and  easily  digested  charac- 
ter. Cool  water  should  be  given  freely.  Antitoxin  should 
be  administered  in  every  case  at  the  earliest  possible  moment. 
In  pharyngeal  cases  the  initial  dose  should  be  from  3000  to 
4000  units.  If  no  decided  improvement  follows  within 
twelve  hours,  the  dose  should  be  repeated.  Laryngeal  cases 
require  from  6000  to  8000  units.  The  injections  may  be 
made  into  the  loose  subcutaneous  tissue  of  the  pectoral 
region,  side  of  the  abdomen,  or  interscapular  space.  Strict 
antiseptic  precautions  should  be  taken  in  the  operation. 

Apart  from  antitoxin,  the  most  important  remedies  are 
those  which  tend  to  maintain  the  bodily  strength.  Alcoholic 
stimulants  are  usually  indicated,  especially  in  the  late  stage 
of  the  disease.  In  septic  cases  alcohol  is  particularly  well 
borne,  a  child  of  three  years  often  being  able  to  take  several 


< 


ERYSIPELAS.  319 

ounces  of  whisky  a  day  with  advantage.  Next  to  alcohol, 
strychnin  (y^Q-  grain  every  three  or  four  hours)  is  the  best 
stimulant.  In  profound  adynamia,  digitalis,  caffein,  camphor, 
and  musk  are  also  useful. 

Local  treatment  is  often  useful.  When,  however,  the 
applications  cause  violent  struggling  and  exhaust  the  child, 
it  is  better  to  desist.  Irrigation  of  the  nose  and  pharynx 
may  be  practised  every  two  or  three  hours  by  means  of  a 
soft  catheter  attached  to  a  fountain  syringe.  The  solutions 
most  useful  for  the  purpose  are  warm  normal  salt  solution  or  a 
warm  saturated  solution  of  boric  acid.  A  solution  of  hydro- 
gen dioxid  (i  to  3  of  lime-water)  or  the  following  solution 
of  Loffler  may  be  applied  to  the  throat  by  means  of  a  swab  : 

R-     Mentholis ^iiss 

Toluolis        i'T^yi 

Alcoholis  absoluti f^ij- 

Liquoris   ferri  chloridi f^j. — M. 

Externally,  hot  or  cold  applications,  whichever  may  be 
the  more  agreeable,  are  useful  in  relieving  pain  and  soreness 
in  the  throat.  In  laryngeal  cases  tracheotomy  or  intubation, 
preferably  the  latter,  should  not  be  deferred  when  dyspnea 
becomes  urgent. 

Convalescence  must  be  managed  with  special  care  on 
account  of  the  tendency  to  sudden  heart-failure.  Anemia 
will  require  plenty  of  nourishing  food,  and  such  remedies  as 
iron,  arsenic,  and  cod-liver  oil.  Paralysis  usually  yields  to 
strychnin,  combined  with  applications  of  massage  and  elec- 
tricity. 

ERYSIPELAS- 

Definition. — An  acute  infectious  disease  excited  by  the 
Streptococcus  pyogenes,  and  characterized  by  high  fever  and 
a  peculiar  inflammation  of  the  skin  and  subcutaneous  tissues. 

Ktiology. — The  disease  is  somewhat  contagious,  and  the 
poison  can  be  carried  in  fomites.  Certain  families  and  cer- 
tain individuals  seem  particularly  predisposed.  Puerperal 
women  and  wounded  persons  are  very  susceptible.  Diseases 
which  lower  the  vitality,  especially  Bright's  disease,  predis- 


320  ACUTE  INFECTIOUS  DISEASES. 

pose.  One  attack  does  not  protect  against  a  recurrence, 
but  rather  favors  it.  Erysipelas  was  formerly  divided  into 
traumatic  and  idiopathic  varieties ;  but  the  two  are  identical, 
and  it  is  probable  that  in  those  cases  in  which  there  is  no 
conspicuous  wound  there  is  a  slight  abrasion  through  which 
the  poison  gains  admittance. 

The  exciting  cause  is  the  Streptococcus  pyogenes. 

Pathology. — Erysipelas  most  frequently  manifests  itself 
on  the  face.  The  part  is  bright  red  in  color,  swollen,  indu- 
rated, and  sharply  circumscribed.  The  various  strata  of  the 
skin  are  infiltrated  with  serum,  and  leukocytes  and  strepto- 
cocci are  found  in  the  lymph-spaces.  In  severe  cases  the 
inflammatory  products  are  converted  into  pus,  and  abscesses 
form. 

Period  of  Incubation. — Three  to  seven  days. 

Symptoms. — Prodromes  are  sometimes  present,  and  con- 
sist of  slight  fever,  chilliness,  malaise,  and  tingling  of  the 
part  to  be  affected.  In  many  cases  the  disease  is  ushered  in 
suddenly  with  a  chill,  followed  by  pain  in  the  head  and  limbs 
and  a  high,  irregular  fever.  The  temperature  may  reach 
104°  or  105°  F.  in  twelve  or  twenty-four  hours.  The  pulse 
is  full  and  rapid  ;  the  tongue  is  heavily  coated ;  the  appetite 
is  lost ;  the  bowels  are  constipated ;  and  the  urine  is  scanty 
and  often  slightly  albuminous.  There  is  usually  a  marked 
leukocytosis. 

Local  Phenomena. — The  inflammation  usually  begins  in 
the  neighborhood  of  the  nose,  and  spreads  upward  and 
laterally  over  the  head  to  the  neck,  where  it  frequently 
stops.  The  affected  part  has  a  crimson  hue  ;  it  is  swollen 
and  tense,  and  frequently  ends  in  a  sharply  defined  ridge, 
beyond  which,  however,  projections  can  be  felt  advancing 
into  the  subcutaneous  tissue.  The  surface  of  the  inflamed 
patch  is  at  first  smooth  and  glazed,  but  later  it  is  covered 
with  minute  vesicles  or  blebs.  The  patient  complains  of 
burning  and  tingling ;  the  surrounding  parts  are  extremely 
edematous,  so  that  the  features  may  be  scarcely  recogniza- 
ble. In  four  or  five  days  the  redness  begins  to  fade  and  the 
swelling  to  subside ;  desquamation  follows ;  the  general 
symptoms  improve  ;  and  the  fever  falls  by  crisis.     The  aver- 


ERYSIPELAS.  32 1 

age  duration  is  from  a  week  to  ten  days.     Relapses  are  ex- 
tremely common. 

Erysipelas  Ambiilans. — Sometimes  the  inflammation  dis- 
appears in  one  place  and  reappears  in  another,  and  so  con- 
tinues indefinitely.  In  such  cases  typhoid  symptoms,  such 
as  muttering  deHrium,  a  brown,  fissured  tongue,  and  subsul- 
tus  tendinum,  develop. 

Complications. — These  are  not  very  common.  Septi- 
cemia, ulcerative  endocarditis,  nephritis,  acute  rheumatism, 
edema  of  the  larynx,  pneumonia,  and  meningitis  are  occa- 
sionally seen. 

Diagnosis. — Erythema. — ^The  absence  of  high  fever,  of 
marked  sweUing,  and  of  an  abrupt  ridge  will  serve  to  dis- 
tinguish erythema  from  erysipelas. 

Acute  Eczema. — The  swelling  is  less  marked  ;  the  itching 
is  intense  ;  the  swelling  and  redness  are  not  circumscribed, 
but  shade  gradually  into  healthy  tissue  ;  and  there  is  no 
fever. 

Prognosis. — In  the  robust  the  prognosis  is  favorable. 
In  the  old,  in  alcohoHc  subjects,  and  in  those  suffering  from 
chronic  nephritis  the  prognosis  must  be  guarded.  Ambu- 
latory erysipelas  may  kill  by  exhaustion. 

Treatment. — As  in  other  contagious  diseases,  isolation 
and  disinfection  are  the  most  important  prophylactic  measures. 
Especially  necessary  is  it  to  guard  parturient  and  surgical 
patients  from  the  contagion. 

A  supporting  liquid  diet  should  be  given.  Alcoholic 
stimulants  are  sometimes  required  in  considerable  quantities. 
High  fever  is  best  controlled  by  cold  sponging  or  the  cold 
pack.  Restlessness,  delirium,  and  insomnia  will  call  for  ap- 
plications of  ice  to  the  head,  and  perhaps  the  administration 
^  of  morphin,  chloral,  or  bromids. 

I  Of  the  numerous  special  remedies  recommended  for  erysipe- 
las, the  one  which  has  enjoyed  the  most  favor  is  the  tincture 
of  ferric  chlorid  (15  to  30  minims  every  three  hours). 

Local  Treatment. — Among  the  numerous  local  applica- 
tions recommended  may  be  mentioned  :  Lotions  of  lead- 
water  and  laudanum,  of  carbolic  acid  (i  140),  of  picric  acid 
(i  :  100),  and  of  sodium  sahcylate  (i  :  20).     In  the  hands  of 

21 


322  ACUTE   INFECTIOUS  DISEASES, 

the  author  ointments  of  ichthyol  (20  per  cent.)  and  of 
soluble  silver  (unguentum  Crede)  have  proved  most  satisfac- 
tory. 

The  following  combination  often  acts  extremely  well : 

R.     Ichthyol gr.  xxx 

Resorcinolis zss 

Unguenti  hydrargyri ^iv 

Adipis  lanae  hydros!  .....    ....  ^v. — M. 

(RoswELL  Park.) 

Local  abscesses  should  be  incised  and  treated  antiseptically. 
Extension  to  the  nose  and  throat  will  call  for  antiseptic 
sprays  or  washes. 

INFLUENZA, 

(La  Grippe ;  Catarrhal  Fever ;   Epidemic  Catarrh.) 

Definition. — An  acute  infectious  disease  characterized 
by  fever,  marked  prostration,  severe  muscular  pains,  and 
catarrhal  inflammation  of  certain  mucous  membranes,  espe- 
cially those  of  the  respiratory  tract. 

etiology. — The  disease  occurs  in  epidemics  that  usually 
have  their  origin  in  Russia,  whence  they  spread  with  won- 
derful rapidity  over  both  continents.  The  exciting  cause 
is  the  extremely  small,  non-motile  bacillus  discovered  by 
Pfeiffer  in  1892.  It  is  readily  obtained  from  the  sputum. 
When  prevalent,  no  age  and  neither  sex  is  exempt.  One 
attack  does  not  confer  immunity  against  others. 

Pathology. — Influenza  does  not  often  kill  except  by  its 
complications.  The  latter  are  most  frequently  associated 
with  the  respiratory  tract,  and  consist  chiefly  of  catarrhal 
pneumonia,  croupous  pneumonia,  and  pleurisy. 

Symptoms. — The  disease  begins  abruptly  with  lassitude, 
malaise,  chilliness,  severe  pain  in  the  head  and  back,  fever 
ranging  between  102°  and  104°  F.,and  extreme  prostration, 
which  is  out  of  proportion  to  the  fever  and  any  existing 
local  inflammation.  The  catarrhal  symptoms  are  injection 
of  the  eyes,  sneezing,  hoarseness,  and  hard  paroxysmal 
cough.  In  simple  cases  the  temperature  falls  in  three  or  four 
days  by  crisis,  but  compHcations  not  infrequently  prolong 
the  case  for  several  weeks. 


INFLUENZA.  323 

In  some  cases  the  catarrh  of  the  respiratory  tract  is  the 
chief  feature;  in  others  the  gastro-intestinal  tract  is  attacked, 
and  the  symptoms  resemble  cholera  morbus ;  in  a  third 
group  neuralgic  pains  in  the  head,  back,  and  Hmbs  are  the 
most  striking  phenomena. 

Complications  and  Sequelae. — The  most  important 
are :  Catarrhal  pneumonia,  croupous  pneumonia,  pleurisy, 
neuritis,  cardiac  neuroses,  and  pericarditis.  Permanent  in- 
sanity is  an  occasional  sequel. 

Diagnosis. — Acute  Bronchitis. — The  fever  is  not  so  high; 
there  is  little  or  no  prostration  ;  and  the  pains  in  the  head 
and  back  are  not  nearly  so  marked  as  in  influenza. 

Typhoid  Fever. — The  gradual  onset,  typical  temperature- 
curve,  epistaxis,  diarrhea,  Widal  reaction,  and  rash  will  indi- 
cate typhoid  fever. 

Prognosis. — Uncomplicated  cases  nearly  always  recover. 
In  the  very  old  and  in  those  debilitated  by  chronic  disease 
influenza  not  infrequently  proves  fatal. 

•  Treatment. — Hygienic  measures  are  of  the  first  im- 
portance ;  these  include  immediate  and  absolute  rest  in  bed, 
a  carefully  selected  diet,  pure  air  without  draft,  and  attentive 
nursing.  Complications  and  relapses  can  generally  be  traced 
to  a  neglect  of  these  rules. 

In  mild  cases  a  hot  foot-bath,  some  mild  refrigerant,  such 
as  spirit  of  nitrous  ether  or  solution  of  ammonium  acetate, 
and  at  night  a  dose  of  Dover's  powder  (5  to  10  grains)  will 
usually  suffice.  If  there  be  constipation,  a  few  fractional 
doses  of  calomel  may  be  given  with  advantage. 

In  more  severe  cases  quinin  (2  to  5  grains  thrice  daily) 
may  be  given  throughout  the  attack.  Pains  are  controlled 
to  some  extent  by  phenacetin  with  salicylates  or  benzoates. 

The  following  combination  is  often  useful : 

5^.    Acetphenetidini 

Salophen 

Sodii  benzoatis aa  ^j. — M. 

Fiant  chartulae  No.  xij. 

SiG. — One  every  three  or  four  hours. 

When  the  suffering  is  intense,  morphin  should  be  used 
hypodermically.     Violent  headache  is  treated  best  by  small 


324  ACUTE   INFECTIOUS  DISEASES. 

doses  of  phenacetin  and  the  application  of  an  ice-cap  to  the 
head. 

Heart-failure  should  be  combated  by  alcohol  and  strychnin. 
Bronchial  catarrh  will  require  the  remedies  indicated  in  simple 
bronchitis.  Sleep  may  be  induced  by  opium,  sulphonal,  or 
chloralamid. 

MUMPS- 
(Epidemic  Parotitis.) 

Definition. — An  acute  contagious  disease,  characterized 
by  inflammation  of  the  parotid  and  other  salivary  glands. 
•  Ktiology. — The  disease  occurs  sporadically  and  epi- 
demically. It  is  most  frequently  observed  in  young  children, 
but  unprotected  adults  are  not  exempt.  Males  are  more 
susceptible  than  females.  The  disease  is  highly  contagious, 
and  the  virus  is  probably  contained  in  the  saliva,  but  it  has 
not  been  isolated.  One  attack  confers  immunity  against 
others. 

Pathology. — As  the  disease  is  so  seldom  fatal,  very 
little  opportunity  is  afforded  for  studying  its  intimate  path- 
ology. The  parotid  glands  are  the  seat  of  an  inflammatory 
infiltration,  but  suppuration  very  rarely  occurs.  In  males 
the  inflammation  shows  a  marked  tendency  to  leave  the 
parotids  and  to  involve  the  testicles.  In  girls,  transference 
of  the  inflammation  to  the  ovary,  vulva,  or  mammary  gland 
is  occasionally  seen. 

Period  of  Incubation. — One  to  three  weeks. 

Symptoms. — The  disease  is  ushered  in  with  chilliness, 
malaise,  and  moderate  fever  (ioi°-i03°  F.),  followed  by 
swelling  of  one  parotid  gland.  The  swelling  is  observed 
below  and  in  front  of  the  ear,  is  pyriform  in  shape,  and  has 
a  doughy  feel.  The  surrounding  tissues  are  edematous,  the 
submaxillary  glands  are  often  swollen,  and  the  features  may 
be  distorted  beyond  recognition.  The  movements  of  the 
jaw  are  restricted  and  painful.  The  saliva  is  usually  much 
diminished,  but  occasionally  it  is  increased.  In  most  cases 
the  other  parotid  becomes, similarly  affected.  The  duration 
of  the  disease  is  from  five  to  seven  days. 

Complications. — Orchitis  is  the  most  important  com- 


YELL  OW  FE  VER.  325 

plication.  It  is  usually  seen  in  adolescence ;  in  childhood 
it  is  very  rare.  Atrophy  of  the  testicle  sometimes  follows. 
Deafness,  nephritis,  suppuration  of  the  gland,  and  pneumonia 
are  rarely  encountered. 

Prognosis. — Favorable. 

Treatment. — The  patient  should  be  kept  in  bed.  Iso- 
lation should  last  three  weeks  from  the  onset  of  the  disease. 
Mild  aperients  and  refrigerants  are  useful.  When  the  pain 
is  severe,  hot  fomentations  containing  laudanum  prove 
soothing.  In  mild  cases,  covering  the  gland  with  cotton 
batting  will  suffice. 

Orchitis  will  require  rest,  suspension  of  the  affected  gland, 
and  the  application  of  lead-water  and  laudanum  or,  better 
still,  of  an  ointment  of  guaiacol  (10  per  cent.).  After  the 
tenderness  has  subsided,  an  ointment  of  mercury  and  bella- 
donna will  be  found  useful  in  reducing  the  sweUing. 

YELLOW  FEVER* 

Definition. — An  acute  infectious,  endemic  or  epidemic 
disease,  characterized  by  fever  of  one  or  two  paroxysms, 
jaundice,  albuminuria,  and  a  marked  tendency  to  hemor- 
rhage, especially  from  the  stomach. 

etiology. — The  specific  organism  of  yellow  fever  has 
not  yet  been  isolated.  Man  is  inoculated  through  the  bites 
of  a  certain  species  of  mosquito, — Stegouiyia  calopus, — 
which  serves  as  the  intermediate  host  for  the  parasite.  The 
mosquito  is  infected  only  by  biting  a  yellow-fever  patient 
during  the  first  three  days  of  the  disease  and  cannot  trans- 
mit the  infection  until  a  period  of  from  twelve  to  twenty 
days  has  elapsed.     The  disease  is  not  conveyed   by  fomites. 

Yellow  fever  occurs  endemically  in  tropical  sea-ports, 
whence  it  occasionally  spreads  to  temperate  zones.  The 
predisposing  factors  are  those  which  are  favorable  to  the 
growth  of  mosquitos — high  temperature,  surface  drainage, 
and  swampy  soil.  The  colored  race  is  less  susceptible 
than  the  white.  Strang-ers  in  an  infected  district  are  more 
liable  to  be  attacked  than  residents.  One  attack  usually 
confers  immunity  from  others. 


326  ACUTE  INFECTIOUS  DISEASES. 

Pathology. — The  tissues  are  stained  yellow.  The  liver 
presents  a  reddish-yellow  (autumn-leaf)  mottled  hue,  and  is 
the  seat  of  extensive  fatty  degeneration.  The  kidneys 
usually  show  the  lesions  of  acute  hemorrhagic  nephritis. 
The  gastro-intestinal  mucous  membrane  is  swollen,  con- 
gested, and  frequently  infiltrated  with  blood.  The  heart- 
muscle  is  pale  and  fatty. 

Period  of  Incubation. — Three  to  four  days. 

Symptoms. — First  Stage. — The  disease  begins  with  a 
chill,  followed  by  pain  in  the  head,  back,  and  limbs.  The 
temperature  rises  rapidly  until  it  reaches  its  maximum 
(i03°-i05°  R). 

The  pulse  is  at  first  accelerated,  but  as  the  temperature 
rises  it  shows  a  marked  tendency  to  fall,  sometimes  dropping 
in  grave  cases  to  80  or  even  to  70  a  minute  by  the  third  day. 
The  face  is  flushed;  the  conjunctivae  are  injected;  the  pupils 
are  small ;  the  tongue  is  coated ;  the  epigastrium  is  tender ; 
the  stomach  is  irritable  and  unretentive ;  the  bowels  are  con- 
stipated ;  and  the  urine  is  scanty  and  often  albuminous  by 
the  end  of  the  first  day. 

Jaundice  is  rarely  marked  before  the  second  or  third  day, 
although  a  slight  icteroid  tinge  of  the  conjunctivae  is  often 
noticeable  within  the  first  twenty-four  hours.  The  first  stage 
usually  lasts  from  three  to  five  days,  and  is  followed  by  a 
rapid  fall  in  the  temperature  and  an  improvement  in  all  the 
symptoms  (stage  of  calm  or  remission).  At  this  time  con- 
valescence may  begin  or  the  patient  may  pass  into  the 
second  stage. 

The  second  stage  is  characterized  by  deep  jaundice,  per- 
sistent vomiting,  vomiting  of  dark  blood  {black  vomit),  marked 
albuminuria,  and  often  by  suppression  of  urine  and  hemor- 
rhages from  the  mucous  surfaces.  The  mind  usually  re- 
mains clear  until  very  near  the  close,  but  in  some  cases 
delirium  and  stupor  develop.  This  stage  may  be  afebrile, 
but  not  infrequently  the  temperature  rises  again  after  the 
period  of  calm,  while  the  pulse  remains  extremely  low  (50  to 
40  a  minute).  Death  usually  results  from  collapse  or  uremia. 
The  duration  of  the  disease  is  from  three  to  ten  days. 

Diagnosis. — Dengue. — This  disease   does  not  exhibit  a 


ACUTE    GENERAL    TUBERCULOSIS.  327 

slow  pulse  with  a  rising  temperature,  early  albuminuria, 
jaundice,  or  black  vomit. 

Acute  Yellow  Atrophy  of  the  Liver. — The  rapid  pulse,  the 
diminution  in  the  size  of  the  liver,  the  slight  fever,  the  marked 
cerebral  symptoms,  and  the  presence  of  leucin  and  tyrosin 
in  the  urine  will  indicate  acute  yellow  atrophy. 

Remittent  Fever. — This  may  be  distinguished  by  the  en- 
largement of  the  spleen,  the  multiple  remissions,  the  presence 
in  the  blood  of  the  hematozoa  of  Laveran,  and  by  the  «absence 
of  black  vomit. 

Prognosis. — Always  grave.  The  average  mortaHty  in 
different  epidemics  is  from  20  to  70  per  cent.  In  individual 
cases  high  fever,  a  very  slow  pulse,  marked  cerebral  symp- 
toms, black  vomit,  and  suppression  of  urine  are  unfavorable 
features. 

Treatment. — "  The  spread  of  yellow  fever  can  be  most 
effectually  controlled  by  measures  directed  to  the  destruction 
of  mosquitos  and  the  protection  of  the  sick  from  the  bites  of 
these  insects."  ^ 

Absolute  rest  in  a  quiet,  well-ventilated  room  and  careful 
nursing  are  essential.  Only  the  blandest  food  should  be 
allowed.  Many  clinicians  of  wide  experience  advocate  the 
withholding  of  all  food  during  the  first  day  or  two.  For  the 
gastric  irritability  a  sinapism  may  be  applied  to  the  epigas- 
trium, and  cracked  ice,  champagne,  hydrocyanic  acid,  or 
cocain  may  be  given  internally.  Fever  is  best  controlled  by 
the  external  application  of  cold.  Suppression  of  urine  will 
call  for  dry  cupping  over  the  loins,  alkaline  diuretics,  hot-air 
baths,  and  subcutaneous  or  rectal  injections  of  warm  saline 
solutions.  Remedies  have  little  effect  upon  the  black  vomit. 
Tincture  of  ferric  chlorid,  adrenalin  solution  (i  :  looo),  and 
oil  of  turpentine  have  been  recommended. 

ACUTE  GENERAL  TUBERCULOSIS* 

(Acute  Miliary  Tuberculosis.) 

Definition. — An  acute  infectious  disease  excited  by  the 
tubercle   bacillus,    and    characterized   anatomically   by   the 

1  Report  of  U.  S.  Army  Commission,  ybz^n  Hyg.y  vol.  ii.,  No.  2. 


328  ACUTE   INFECTIOUS  DISEASES. 

simultaneous  formation  of  miliary  tubercles  in  many  parts 
of  the  body. 

etiology. — The  disease  usually  develops  in  early  adult 
life.  Certain  infectious  diseases,  like  measles  and  whooping- 
cough,  seem  to  predispose.  General  tuberculosis  is  almost 
always  secondary  to  local  tuberculosis — pulmonary  phthisis 
or  a  scrofulous  lymphatic  gland.  The  bacilli  are  probably 
disseminated  by  the  veins. 

Pathology. — All  the  organs  may  be  uniformly  infil- 
trated with  discrete  tubercles,  but  more  commonly  certain 
organs,  like  the  brain  and  lungs,  are  more  affected  than 
others. 

Symptoms. — The  onset  is  gradual  and  characterized  by 
anorexia,  malaise,  headache,  increasing  prostration,  and  fever. 
The  temperature  is  moderately  high  ( 1 02°- 104°  F.),  very 
irregular,  and  marked  by  evening  exacerbations  and  morning 
remissions.  The  respirations  are  hurried  and  the  pulse  is 
rapid  (140  to  150)  and  feeble.  Cough  may  or  may  not  be 
present.  As  the  disease  advances  typhoid  symptoms  develop 
— brown,  fissured  tongue,  muttering  delirium,  subsultus  ten- 
dinum,  carphologia,  and  stupor.  Tubercle  bacilli  are  rarely 
found  in  the  sputum  or  in  the  blood. 

Wheji  the  lungs  are  chiefly  affected,  there  are :  Dyspnea, 
rapid  breathing  (40  to  60  a  minute),  hard  cough,  mucopuru- 
lent and  bloody  expectoration,  and  cyanosis.  Signs  of  con- 
solidation can  rarely  be  elicited,  but  auscultation  usually 
reveals  sibilant  and  moist  rales. 

When  the  meninges  are  chiefly  affected,  there  are :  Intense 
headache,  convulsive  seizures,  photophobia,  delirium,  facial 
palsies,  stupor,  coma,  and  Cheyne-Stokes  breathing.  Tu- 
bercles may  occasionally  be  detected  on  the  retina. 

Wheii  the  intestines  and  peritoneum  are  affected,  there  are : 
Pain,  tenderness,  abdominal  distention,  and  diarrhea. 

Prognosis. — The  disease  is  always  fatal  The  duration 
is  from  three  to  eight  weeks. 

Diagnosis. — The  disease  closely  resembles  typhoid  fever, 
and  there  is  no  doubt  that  the  mortality  of  the  latter  is  en- 
hanced by  included  cases  of  unsuspected  general  tubercu- 
losis. 


WHOOPING-COUGH.  329 

Typhoid  Fever.  Acute  General  Tuberculosis. 

Epistaxis  is  common.  Infrequent. 

Temperature  runs  a  regular  course.  Temperature    runs    a    very   irregular 

course. 

Diarrhea  is  frequent.  Infrequent. 

Aroseolar  eruption  is  generally  present.  Rarely  present. 

Respirations  are  rapid.  Usually  much  more  rapid. 

Pulse  is  rapid.  Usually  much  more  rapid. 

Cyanosis  rarely  marked.  Often  distinct. 

Facial  palsies  are  absent.  Are  occasionally  noticeable. 

Widal  reaction  is  present.  Is  absent. 

Treatment. — This  is  purely  palliative.  The  diet  should 
consist  of  rnilk,  eggs,  and  broths.  Stimulants  are  required. 
Fever  should  be  controlled  by  cold  sponging  or  small 
doses  of  phenacetin.  Severe  cough  and  insomnia  will  call 
for  morphin. 

WHOOPING-COUGH* 

(Pertussis.) 

Definition. — An  infectious  disease,  characterized  by  ca- 
tarrh of  the  respiratory  tract  and  peculiar  paroxysms  of 
cough  ending  in  prolonged  crowing  or  whooping  inspiration. 

!^tiolo§y. — The  disease  occurs  both  sporadically  and 
epidemically.  It  is  most  frequently  met  with  in  children, 
but  unprotected  adults  are  not  exempt.  The  disease  is 
unquestionably  contagious,  and  the  virus  seems  to  be  asso- 
ciated with  the  sputum.     One  attack  protects  from  others. 

Patholog'y. — No  characteristic  lesions  are  observed  after 
death.  The  poison  excites  an  inflammation  of  the  respira- 
tory mucous  membrane,  and  probably  irritates  the  periph- 
eral filaments  of  the  pneumogastric  nerve,  and  so  causes 
the  paroxysmal  cough.  In  fatal  cases  pulmonary  compli- 
cations are  usually  discovered,  such  as  catarrhal  pneumonia, 
pulmonary  collapse,  and  emphysema. 

Symptoms. — There  are  three  stages:  (i)  The  catarrhal 
stage ;  (2)  the  paroxysmal  stage ;  and  (3)  the  stage  of 
decline. 

Catarrhal  Stage. — The  disease  begins  with  the  symptoms 
of  coryza  and  bronchial  catarrh, — slight  fever,  sneezing, 
running  from  the  nose,  dry  cough,  and  rales, — but  it  does 


I 


330  ACUTE   INFECTIOUS  DISEASES. 

not  respond  to  the  ordinary  remedies  for  catarrh,  and  after 
lasting  one  or  two  weeks  passes  into  the  paroxysmal  stage. 

Paroxysmal  Stage. — The  cough  becomes  more  violent 
and  paroxysmal.  During  the  paroxysm  the  face  is  cyanosed, 
the  eyes  are  injected,  and  the  veins  distended.  The  cough 
frequently  induces  vomiting,  and,  in  severe  cases,  epistaxis 
or  other  hemorrhages.  The  close  of  the  paroxysm  is 
marked  by  a  long-drawn,  shrill,  whooping  inspiration  due 
to  the  spasmodic  closure  of  the  glottis. 

The  number  of  paroxysms,  or  "  kinks,"  varies  from  ten 
or  twelve  to  forty  or  fifty  in  the  twenty-four  hours.  From 
the  forcible  propulsion  of  the  tongue  against  the  lower 
incisors,  an  ulcer  is  frequently  formed  on  the  frenum.  The 
duration  of  this  stage  is  three  or  four  weeks. 

Stage  of  Decline. — The  paroxysms  grow  less  frequent  and 
less  violent  and  finally  cease.  Protracted  cases  are  followed 
by  anemia  and  prostration. 

Duration. — The  entire  duration  of  the  disease  is  from  a 
few  weeks  to  four  months. 

Complications  and  Sequelae. — The  chief  are  broncho- 
pneumonia, collapse  of  the  lung,  acute  emphysema,  and 
hemorrhage  from  the  nose  or  into  the  conjunctiva.  Paral- 
ysis from  meningeal  hemorrhage  occasionally  occurs.  Severe 
cases  are  sometimes  followed  by  cancrum  oris,  chronic 
bronchitis,  or  tuberculosis. 

Treatment. — Prophylaxis  consists  in  isolation  of  the 
patient  and  the  thorough  disinfection  of  all  articles  that 
have  been  used  by  him.  Quarantine  should  last  until  the 
cough  ceases. 

Fresh  air,  sunlight,  proiection  from  changes  of  weather, 
and  a  light  but  nutritious  diet  are  essential.  In  some  cases 
it  may  be  desirable  to  keep  the  patient  in  his  room,  or  even 
in  bed,  for  the  first  few  days,  but  ordinarily,  if  the  weather 
is  efood,  he  need  not  be  confined  indoors.  In  advanced 
cases  sea-air  often  acts  most  favorably. 

Of  the  many  special  remedies  advocated,  those  most 
worthy  of  confidence  are  belladonna  (in  ascending  doses 
until  constitutional  effect  is  produced),  antipyrin  (i  grain 
every  two  hours   at  one  year  of  age),   quinin  (lO  grains  a 


I 


CHOLERA.  331 

day  at  three  years  of  age),  brorrioform  (i  to  2  minims  at 
two  years  of  age),  and  sodium  bromid  (3  to  5  grains  every 
three  hours  at  two  years  of  age).  Chloral  (3  grains  at  two 
years  of  age)  may  be  given  in  severe  cases  at  bedtime  to 
secure  sleep.  Such  a  combination  as  the  following  is  often 
useful : 

R.    Sodii  bromidi gr.  1 

Antipyrinae gr.  xv 

Glycermi f.^ss 

Aquae  menthse  piperitae  .    .    .    q.  s.  ad   f^iij. — M. 

SiG. — A  teaspoonful  every  two  hours  for  a  child  one  year  old. 

Antiseptic  and  sedative  sprays,  when  feasible,  sometimes 
afford  much  relief;  the  best  are  the  solution  of  hydrogen, 
dioxid  (i  to  6),  menthol  (5  per  cent,  in  liquid  paraffin),  and 
resorcin  (i  per  cent,  aqueous  solution). 

The  child  must  be  carefully  guarded  during  convales- 
cence, on  account  of  the  great  danger  of  catarrhal  pneu- 
monia. Tonics,  especially  quinin,  iron,  and  cod-liver  oil^ 
are  very  useful  at  this  period. 

CHOLERA* 

(Asiatic  Cholera ;  Epidemic  Cholera ;  Malignant  Cholera.) 

Definition. — An  acute  infectious  disease,  generally  epi- 
demic, excited  by  Koch's  comma-bacillus,  and  characterized 
by  vomiting  and  purging  of  serous  material,  painful  cramps, 
and  collapse. 

etiology. — Cholera  is  constantly  present  in  certain  parts 
of  India,  and  under  favorable  conditions  is  carried  thence  to 
other  parts  of  the  world.  The  exciting  cause  is  the  comma- 
bacillus  of  Koch,  a  short,  slightly  curved,  motile  rod  with 
a  single  flagellum.  This  organism  is  found  abundantly  in 
the  intestinal  discharges  of  choleraic  patients.  Outside  the 
body  its  growth  is  favored  by  heat  and  decomposing  animal 
matter. 

The  disease  always  spreads  along  the  lines  of  traffic,  hence 
epidemics  nearly  always  begin  at  the  sea-coast  and  extend 
inland.  Cholera  is  sHghtly,  if  at  all,  contagious  ;  Hke  typhoid 
fever,  the  poison  is  not  carried  through  air,  but  chiefly  through 
drinking-water  and  food.     Flies  are  undoubtedly  important 


332  ACUTE  INFECTIOUS   DISEASES. 

factors  in  conveying  the  germs  to  food.  Laundresses  and 
nurses,  from  their  contact  with  the  evacuations,  readily  acquire 
the  disease.  Epidemics  are  more  frequent  in  summer  than 
in  winter.  No  age  is  exempt,  but  the  old  are  more  suscep- 
tible than  the  young.  The  intemperate,  the  debilitated,  and 
those  suffering  with  gastro-intestinal  catarrh  are  especially 
predisposed. 

Pathology. — The  body  is  shriveled  ;  movements  of  the 
corpse  are  sometimes  observed  ;  rigor  mortis  is  marked  and 
prolonged.  The  tissues  are  dry,  and  the  large  veins  and 
right  side  of  the  heart  contain  thick,  dark  blood.  The 
serous  cavities  are  empty  and  their  surfaces  sticky.  The  in- 
testines contain  more  or  less  rice-water  fluid,  from  which  cul- 
tures of  bacilli  can  be  made. 

The  mucous  membrane  has  a  pinkish  color  and  is  often 
the  seat  of  ecchymoses ;  the  solitary  and  Peyer's  glands  are 
swollen.  Frequently  extensive  desquamation  of  the  epithe- 
lial lining  is  observed.  The  liver  and  kidneys  are  the  seat 
of  acute  parenchymatous  degeneration. 

The  symptoms  of  cholera  are  doubtless  due  to  the  absorp- 
tion of  poisonous  substances  elaborated  by  the  bacilli  in  the 
intestines. 

Period  of  Incubation. — Three  to  five  days. 

Symptoms. — The  severity  of  the  symptoms  varies  con- 
siderably. In  well-marked  but  favorable  cases  there  are 
three  stages  :  (i)  Invasion;  (2)  algid  or  collapse;  (3)  re- 
action. 

Stage  of  Invasion. — The  disease  usually  begins  with  ma- 
laise, headache,   diarrhea,  rumbling  noises  in  the  intestines, 
and  colic.     Frequently  these  symptoms  continue  a  few  days 
and  then  subside ;  such  cases  are  termed  cholerine,  and  are    j 
as  infectious  as  the  fully  developed  disease.  I 

Stage  of  Collapse. — The  diarrhea  grows  more  marked  ; 
the  evacuations  become  copious,  lose  their  feculent  character, 
assume  a  rice-water  appearance,  and  are  discharged  forcibly 
but  without  pain.  Vomiting  soon  develops,  and  the  ejected 
material  resembles  that  passed  by  the  bowels.  Thirst  is  un- 
quenchable. Severe  cramps  seize  the  muscles  of  the  calves  | 
of  the  legs,  thighs,  arms,  and  abdomen.     The  surface  is  cold    ° 


CHOLERA.  333 

and  covered  with  a  clammy  sweat ;  the  breath  is  cool ;  the 
temperature  in  the  axilla  ranges  from  95°  to  85°  F.,  while 
in  the  rectum  it  may  rise  to  103°  F.  or  more.  The  voice  is 
husky  and  finally  reduced  to  a  whisper  ;  the  respirations  are 
quickened ;  the  pulse  becomes  more  and  more  feeble ;  the 
body  is  livid  and  shriveled ;  the  hands  resemble  those  of  a 
washerwoman  ;  the  features  are  pinched  and  sometimes  dis- 
torted ;  the  eyes  are  frightfully  sunken.  The  urine  is  more 
or  less  suppressed,  and  the  little  that  is  passed  generally 
contains  albumin  and  sugar.  Consciousness  is  usually 
retained  until  near  the  end,  when  coma  sets  in. 

The  duration  of  this  stage  is  from  a  few  hours  to  two 
days. 

Stage  of  Reaction. — Sometimes,  even  when  death  seems 
imminent,  the  surface  temperature  begins  to  rise;  the  urine 
increases ;  the  pulse  strengthens ;  the  vomiting  ceases ;  the 
evacuations  from  the  bowels  become  less  frequent  and  begin 
to  assume  a  feculent  character,  and  convalescence  is  ulti- 
mately established. 

Occasionally,  instead  of  convalescence,  symptoms  of  a 
typhoid  type  develop,  such  as  moderate  fever,  a  brown, 
fissured  tongue,  subsultus,  muttering  delirium,  and  coma. 
This  condition,  which  is  generally  fatal,  has  been  regarded 
as  uremic. 

Cholera  Sicca. — In  very  violent  cases  collapse  and  death 
may  follow  without  there  having  been  any  evacuation.  After 
death  the  intestines  contain  rice-water  fluid,  which  was  not 
discharged  during  life  probably  on  account  of  paralysis  of 
the  muscular  coat  of  the  bowel. 

Complications  and  Sequelae. — The  chief  complica- 
tions are  :  nephritis,  pneumonia,  pleurisy,  parotitis,  ulcera- 
tion of  the  cornea,  diphtheric  inflammation  of  the  throat  and 
fauces,  abscesses,  and  local  gangrene. 

Diag"nosis. — The  differential  diagnosis  between  Asiatic 
cholera  and  cholera  morbus  has  already  been  considered  (see 

p.  77\ 

Prognosis. — This  depends  largely  upon  the  type.  The 
mortality  averages  about  50  per  cent.  In  the  old,  very 
young,  debilitated,  and  intemperate  the  disease  is  very  fatal. 


334  ACUTE  INFECTIOUS  DISEASES. 

In  individual  cases  early  collapse  and  a  low  surface  tempera^ 
tureare  unfavorable  conditions. 

Treatment. — Personal  prophylactic  measures  against 
the  disease  include  removal  from  the  infected  districts, 
restriction  of  the  diet  to  bland,  easily  digested  food,  thor- 
ough sterilization  of  drinking-water  and  milk,  the  protec- 
tion of  all  food  from  contamination  by  flies  and  other  in- 
sects, the  avoidance  of  overwork,  exposure  to  wet  and  cold, 
and  undue  excitement,  and  the  prompt  treatment  of  any 
gastro-intestinal  disturbance  that  may  arise.  Certain  acids, 
especially  sulphuric  acid,  have  long  been  advocated  as  pre- 
ventives of  cholera.  Finally,  vaccination  with  attenuated 
cholera  cultures,  as  practised  by  Haffkine  in  India,  has 
given  encouraging  results. 

Precautionary  measures  pertaining  to  the  sick  comprise 
isolation,  absolute  cleanliness,  and  the  thorough  disinfection 
of  excreta,  soiled  clothing,  etc. 

The  medicinal  treatment  of  cholera  resolves  itself  into  that 
of  the  prodromal  stage,  that  of  the  algid  stage,  and  that  of 
the  reaction  stage. 

Prodromal  Stage. — From  the  first  appearance  of  diarrhea 
the  patient  should  go  to  bed  and  remain  there.  Food  should 
be  withheld.  If  there  be  a  history  of  indigestible  food  hav- 
ing been  taken,  a  laxative  dose  of  calomel  should  be  given ; 
otherwise,  aperients  should  be  avoided.  Hot  stupes  may 
be  applied  to  the  abdomen.  If  there  is  much  coHc,  mor- 
phia may  be  given  hypodermically.  For  the  diarrhea,  bis- 
muth subnitrate  is  perhaps  the  best  astringent. 

Algid  Stage. — Intravenous  injections  of  warm  saline  solu- 
tions undoubtedly  afford  the  best  means  of  combating  the 
anhydremia  and  of  restoring  the  failing  circulation.  Rectal 
injections  of  hot  tannic  solutions  (2  per  cent.),  as  strongly 
recommended  by  Cantani,  may  also  be  used.  The  body- 
temperature  should  be  maintained  by  hot  applications  or 
hot  baths.  Diffusible  stimulants,  like  ether  and  camphor, 
may  be  given  hypodermically. 

To  allay  thirst,  ice  or  iced  Seltzer  water  may  be  given  at 
frequent  intervals.  The  painful  cramps  are  best  treated  by 
warm  applications,  hot  baths,  gentle  friction  with  anodyne 


TETANUS.  335 

liniments,  and,  above  all,  by  intermittent  chloroform  inhala- 
tions. In  suppression  of  urine  the  most  promising  measures 
are  dry  cupping  over  the  loins  and  rectal  and  intravenous 
injections  of  saline  solutions. 

Reaction  Stage. — In  this  stage  liquid  foods  in  small  quan- 
tities are  permissible.  Milk  with  lime-water,  whey,  thin 
gruels,  albumin-water,  and  light  broths  are  the  most  appro- 
priate. The  return  to  ordinary  food  should  be  effected  most 
gradually. 

TETANUS. 
(Lockjaw.) 

Definition. — An  acute  infectious  disease  excited  by  a 
special  bacillus,  and  characterized  by  painful  tonic  spasms 
of  the  voluntary  muscles. 

Etiology. — The  exciting  cause  is  the  Bacillus  tetani,  a 
motile,  spore-bearing,  anaerobic  rod,  multiplying  in  garden- 
earth,  street  dirt,  and  the  intestinal  discharges  of  herbivorous 
animals.  The  disease  is  contracted  through  infection  of 
wounds  with  matters  containing  the  bacillus  or  its  spores. 
Lacerated  and  punctured  wounds  about  the  soles  of  the 
feet  and  palms  of  the  hands  are  especially  liable  to  become 
infected.  Occasionally  no  history  of  injury  is  obtainable. 
The  colored  race  appears  to  be  particularly  vulnerable. 

Pathology. — There  are  no  characteristic  lesions.  Con- 
gestion of  the  spinal  cord  and  of  the  nerves  leading  to  the 
wound  is  sometimes  seen.  The  bacillus  produces,  at  the 
point  of  inoculation,  an  intensely  virulent  poison,  which, 
being  absorbed,  vents  itself  in  a  special  manner  upon  the 
central  nervous  system. 

Period  of  Incubation. — From  a  few  days  to  three  or 
four  weeks. 

Symptoms. — The  disease  begins  with  a  feeling  of  rigidity 
in  the  muscles  of  the  neck  and  lower  jaw;  by  degrees  the 
muscles  of  the  back,  abdomen,  and  lower  extremities  are 
similarly  involved.  The  brow  is  wrinkled,  the  corners  of 
the  mouth  are  drawn  upward  (risus  sardonicus),  the  jaws  are 
tightly  closed  {trismus),  and  the  body  becomes  arched,  the 
patient  resting  on  his  head  and  heels  {opisthotonos).     There 


336  ACUTE  INFECTIOUS  DISEASES. 

is  extreme  hyperesthesia,  so  that  the  slightest  touch  causes 
a  violent  exacerbation  of  the  spasm,  which  is  attended  by 
excruciating  pain.  If  the  respiratory  muscles  are  involved, 
there  is  intense  dyspnea.  The  temperature  is  variable.  It 
is  usually  elevated  during  the  paroxysms  and  just  before 
death  it  may  rise  to  107°  F.  or  more.  The  mind  is  clear  to 
the  end.     The  duration  is  from  a  few  days  to  several  weeks. 

Prognosis. — In  acute  cases  the  prognosis  is  very  grave 
death  usually  resulting  within  a  week  from  heart-failure, 
asthenia,  or  asphyxia.  Cases  developing  after  a  long  period 
of  incubation  and  not  characterized  by  violent  seizures  not 
infrequently  end  in  recovery. 

Treatment. — The  wound  should  be  enlarged,  freed  from 
all  foreign  matter,  and  treated  with  some  active  antiseptic. 
The  most  hopeful  means  of  neutralizing  the  toxin  already 
absorbed  is  the  prompt  injection  of  tetanus  antitoxin  in 
large  doses. '  The  drugs  most  effective  in  subduing  the  con- 
vulsions are  the  bromids  and  chloral.  These  should  be 
given  in  large  doses.  Morphin  and  eserin  are  useful  adju- 
vants. Inhalations  of  chloroform  or  of  amyl  nitrite  afford 
temporary  relief.  The  patient  should  be  kept  absolutely 
quiet  and  protected  from  cold.  The  administration  of  nutri- 
ment in  liberal  quantities  is  of  the  utmost  importance.  Alco- 
hol is  often  necessary. 

DENGUE* 
(Breakbone  Fever;  Dandy  Fever.) 

Definition. — An  acute  infectious  disease,  characterized 
by  pains  in  the  muscles  and  joints,  a  variable  rash,  and  a 
febrile  course  of  two  paroxysms. 

etiology. — Dengue  is  confined  almost  entirely  to  hot 
climates.  Although  it  occurs  in  epidemics,  its  contagious- 
ness is  still  a  matter  of  dispute. 

Period  of  Incubation. — Three  to  five  days.  * 

Syniptoms. — The  invasion  is  usually  sudden,  and  is 
attended  with  lassitude,  chilliness,  headache,  intense  pain  in 
the  muscles  and  joints,  and  high  fever.  The  latter  rises 
rapidly,  often  reaching  a  maximum  of  104°  to  105°  F.  in 


HYDROPHOBIA,  337 

a  few  hours.  The  pulse  is  rapid  and  full ;  the  respirations 
are  accelerated ;  the  mind  is  often  delirious ;  the  urine  is 
scanty;  the  superficial  lymph-glands  are  enlarged;  the 
joints  are  painful,  tender,  and  swollen.  In  two  or  three 
days  the  temperature  falls,  and  an  afebrile'  period  follows  in 
which  the  patient  is  free  from  pain,  but  is  profoundly  pros- 
trated. During  the  remission  a  roseolar  or  a  diffuse  ery- 
thematous rash  generally  appears ;  this  lasts  two  or  three 
days  and  is  followed  by  slight  desquamation.  Shortly  after 
the  subsidence  of  the  rash  the  fever  and  pains  again  return, 
and  persist  for  two  or  three  days,  when  convalescence 
begins. 

Diagfnosis. — Acute  Rheumatism. — This  disease  runs  a 
more  protracted  course,  and  lacks  the  paroxysmal  character 
and  the  eruption  of  dengue. 

Prognosis. — Favorable. 

Treatment. — There  is  no  specific  remedy.  A  mercurial 
aperient  should  be  given  at  the  onset.  The  pains  are  best 
relieved  by  phenacetin,  salicylates,  and  morphin.  The  diet 
should  be  liquid  and  sustaining. 

HYDROPHOBIA. 

(Rabies.) 

Definition. — A  specific  infectious  disease  of  certain  car- 
nivorous animals,  especially  dogs  and  wolves,  communicated 
to  man  by  direct  inoculation,  and  characterized  by  slight 
fever,  intense  spasm  of  the  muscles  of  the  throat,  delirium, 
paralysis,  and  coma. 

!Etiology. — Rabies  invariably  results  from  the  bite  of  a 
rabid  animal,  generally  a  dog.  In  the  animal  the  disease  is 
characterized  by  depression  of  spirits,  loss  of  appetite,  fol- 
lowed by  excitement,  aimless  roving,  a  morbid  desire  to  bite, 
and  finally  by  paralysis  and  deatli  from  exhaustion.  The 
poison  is  contained  in  the  central  nervous  system  and  secre- 
tions, especially  the  saliva.  Bites  on  the  face  and  on  exposed 
parts  are  particularly  liable  to  be  followed  by  Infection. 

Pathology. — The  bacteriology  is  obsciJ»-^  Microscoi^*- 
cally,  the  intervertebral  ganglia  present  advancfc^-  prolifera- 

£2 


k 


338  ACUTE  INFECTIOUS  DISEASES. 

tion  of  the  capsular  cells,  with  degeneration  of  the  ganglion 
cells,  and  the  medulla  and  pons,  accumulations  of  deeply 
staining  nuclei  around  the  blood-vessels  (vascular  tubercles 
of  Babes). 

Period  of  Incubation. — From  two  weeks  to  two 
months. 

Symptoms. — The  onset  is  characterized  by  slight  fever, 
anxiety,  depression,  restlessness,  and  pain  in  the  wound  or 
cicatrix.  In  about  a  day  symptoms  of  the  coitvulsive  stage 
appear.  These  consist  in  great  difficulty  in  swallowing, 
severe  clonic  spasms  of  the  laryngeal  muscles,  salivation, 
extreme  hyperesthesia,  hallucinatory  dehrium,  and  prostra- 
tion. Anything  that  excites  the  swallowing  reflex,  such  as 
the  sight  of  water,  may  bring  on  the  painful  spasm  of  the 
throat  muscles.  In  the  course  of  one  or  two  days,  if  the 
patient  does  not  die  from  exhaustion  or  heart-failure,  the 
paralytic  stage  supervenes,  in  which  the  convulsions  and 
delirium  give  way  to  ascending  paralysis  and  unconscious- 
ness. 

Diagnosis. — Hysteria  in  persons  who  have  been  bitten 
may  simulate  hydrophobia.  Such  persons  often  bark,  try  to 
bite,  and  manifest  other  symptoms  which  are  not  noted  in 
hydrophobia. 

Prognosis. — Once  developed,  the  disease  is  invariably 
fatal. 

Treatment. — Prophylaxis. — Suspicious  bites  should  be 
thoroughly  disinfected  and  cauterized  with  caustic  potash  or 
strong  carbolic  acid. 

The  results  obtained  at  the  Pasteur  Institute  at  Paris  seem 
to  Justify  the  inoculative  treatment,  in  which  the  person 
who  has  been  bitten  is  promptly  subjected  to  a  series  of 
inoculations  with  properly  prepared  spinal  cords  from  arti- 
ficially infected  rabbits.  The  treatment  of  the  attack  is  purely 
palliative.  An  attempt  should  be  made  to  maintain  nutrition 
by  rectal  alimentation  and  to  control  the  convulsive  parox- 
ysms by  injections  of  morphin  and  inhalations  of  chloroform. 


CONSTITUTIONAL  DISEASES. 


RHEUMATIC  FEVER. 

(Acute  Articular  Rheumatism;  Inflammatory  Rheumatism.) 

Definition. — An  acute  disease,  characterized  by  poly- 
arthritis, irregular  fever,  acid  sweats,  and  a  marked  tendency 
to  endocardial  inflammation. 

Ktiology. — The  disease  is  most  common  in  the  second 
and  third  decades.  Males  are  more  often  attacked  than 
females.  It  is  most  prevalent  in  moist,  cold  climates. 
Heredity,  lowered  vitality,  and  exposure  are  predisposing 
factors.    Disposition  to  recurrence  is  a  characteristic  feature. 

The  exciting  cause  is  still  unknown.  Most  authorities, 
however,  concede  that  the  disease  is  infectious. 

Patllolog"y. — The  ligaments  and  the  synovial  membrane 
and  its  fringes  are  congested  and  swollen.  The  synovial  sac 
is  filled  with  a  turbid  fluid.  The  cartilages  are  roughened 
and  occasionally  ulcerated.  Generally  the  process  ends  in 
resolution  ;  sometimes  the  surrounding  tissues  become  infil- 
trated with  inflammatory  lymph  and  false  ankylosis  results ; 
very  rarely,  suppuration  of  the  joint  follows.  The  blood 
shows  an  excess  of  fibrin,  a  considerable  diminution  in  the 
number  of  red  cells,  and  an  increase  in  the  number  of  leuko- 
cytes. 

Secondary  inflammations  are  frequently  discovered,  such 
as  endocarditis,  pericarditis,  and  pleurisy. 

Symptoms. — The  symptoms  vary  much  in  their  severity. 
The  disease  usually  begins  abruptly,  or  more  rarely  follows 
such  prodromes  as  malaise,  chilliness,  and  sore  throat.  The 
large  joints,  especially  the  symmetric  ones,  are  usually 
affected;   they  are   slightly   reddened,   swollen,  exquisitely 

339 


340  CONSTITUTIONAL   DISEASES. 

painful,  and  tender  to  the  touch.  The  inflammation  shows 
a  marked  tendency  not  only  to  spread  from  joint  to  joint, 
but  to  disappear  abruptly  in  one  while  it  attacks  another. 
The  joints  most  commonly  involved  are  the  knees,  elbows, 
ankles,  and  wrists,  but  no  joint  is  exempt.  In  severe  cases 
the  muscles  are  painful,  tender,  and  somewhat  rigid.  The 
fever  rises  rapidly  to  a  moderate  height  (i02°-i03°  F.);  it 
is  indefinite  in  its  duration  and  extremely  irregular  in  its 
course.  Perspiration  is  often  copious,  has  a  peculiar  sour 
smell,  and  an  acid  reaction.  The  urine  is  scanty,  high-colored, 
and  on  standing  throws  down  an  abundant  sediment  of 
urates  and  uric  acid.  The  tongue  is  heavily  coated ;  the 
appetite  is  lost ;  the  bowels  are  constipated.  The  face  is  at 
first  flushed,  but  as  the  disease  advances  it  becomes  decidedly 
pale  from  anemia. 

The  duration  is  indefinite,  varying  from  a  few  days  to 
several  weeks. 

Complications. —  Vegetative  endocarditis  is  the  most 
common  complication.  It  occurs  in  about  40  per  cent,  of 
all  cases.  Pericarditis  is  also  common,  but  less  frequent 
than  endocarditis.  Tonsillitis  may  occur  at  the  onset  of  the 
disease.  Certain  cutaneous  affections — urticaria,  purpura, 
erythema  nodosum,  and  subcutaneous  fibrous  nodules  are  oc- 
casionally met  with.  Chorea  sometimes  occurs  after  the 
acute  symptoms  have  subsided.  In  exceptional  cases  the 
subsidence  of  the  joint  inflammation  is  marked  by  the  devel- 
opment of  hyperpyrexia  (io6°-iio°  F.),  and  with  it  marked 
cerebral  symptoms — delirium,  convulsions,  coma.  To  this 
complication  the  term  cerebral  rheumatism  has  been  applied. 

Rarer  compHcations  are  pleurisy,  iritis,  meningitis,  and 
pneumonia. 

Diagnosis. — Septic  Arthritis. — This  may  be  recognized 
by  its  association  with  some  other  septic  process  and  by  the 
special  tendency  of  the  inflammation  to  end  in  suppuration, 
which  is  a  very  rare  termination  of  rheumatic  arthritis. 

Gonorrheal  rheumatism  may  be  recognized  by  the  history 
of  gonorrheal  infection  ;  its  tendency  to  involve  a  single 
joint  and  to  remain  in  the  joint  primarily  affected;  its  long 
duration,  and  its  resistance  to  saHcylates. 


RHEUMATIC  FEVER.  34 1 

Rheumatoid  Arthritis. — This  begins  in  the  small  joints, 
attacking  one  after  another ;  leads  to  permanent  deformity ; 
is  not  associated  with  fever  and  acid  sweats ;  and  shows  no 
tendency  to  involve  the  heart. 

Gout. — This  occurs  later  in  life,  usually  involves  the  great 
toe,  and  lacks  high  fever,  acid  sweats,  and  the  tendency  to 
heart  complications. 

Prognosis. — Most  cases  end  in  recovery.  A  very  small 
number  die  of  exhaustion  or  some  complication,  such  as 
endocarditis  or  hyperpyrexia,  with  grave  nervous  symptoms. 
The  disease  is  very  prone  to  relapse  and  to  recur. 

Treatment. — Absolute  rest  in  a  comfortable  bed  is 
essential,  and,  with  the  view  of  preventing  permanent  injury 
to  the  heart,  this  should  be  maintained  for  at  least  ten  days 
or  two  weeks  after  the  temperature  has  become  normal  and 
all  the  arthritic  symptoms  have  subsided.  The  patient 
should  wear  a  loose  flannel  night-dress  and  lie  between 
blankets.  Milk  and  cereals  are  the  most  suitable  articles 
of  diet.  The  free  use  of  water  and  of  lemonade  should  be 
encouraged.  Two  remedies  have  considerable  power  in  con- 
trolling the  symptoms  :  salicylic  compounds  and  the  alka- 
line salts  of  potassium.  From  lo  to  15  grains  of  ammon- 
ium or  sodium  salicylate  should  be  given  every  two  or  three 
hours  until  a  decided  impression  is  made  upon  the  disease 
or  the  phenomena  of  salicylism  are  produced,  when  the 
interval  between  the  doses  should  be  lengthened  to  four  or 
six  hours.  It  is  advisable  to  continue  the  drug  for  several 
days  after  the  subsidence  of  the  symptoms.  When  the 
ammonium  or  sodium  salt  is  not  well  borne,  strontium 
salicylate  or  salophen  (i    dram  daily)  may  be  substituted. 

If  the  alkaline  treatment  is  employed,  20  to  30  grains  of 
potassium  acetate  or  citrate  should  be  given  every  two  or 
three  hours  until  the  urine  becomes  distinctly  alkaline.  It 
is  often  a  good  plan  to  combine  alkalis  with  salicylates, 
thus: 

R.     Potassii  citratis ^iv 

Sodii  salicylatis i^iij 

Glycerini f^j 

Aquae  menthae  piperitas q.  s.  f^iv. — M. 

SiG. — A  dessertspoonful  every  three  hours. 


342  CONSTITUTIONAL   DISEASES. 

Opium,  in  the  form  of  Dover's  powder  or  of  morphin 
hypodermically,  is  sometimes  of  great  value  in  allaying  pain, 
subduing  restlessness,  and  procuring  sleep.  Antipyrin  or 
phenacetin,  in  moderate  doses,  is  also  a  useful  adjuvant  to 
salicylates  or  alkalis  when  the  pain  is  severe.  When  ady- 
namia is  marked,  quinin  (5  grains)  is  frequently  beneficial. 
Anemic  patients  are  benefited  by  iron. 

Hyperpyrexia  is  best  controlled  by  the  cold  bath.  Endo- 
carditis and  pericarditis  rarely  require  special  remedies. 
The  importance  of  prolonged  rest  in  cases  in  which  the 
heart  becomes  affected  cannot  be  overestimated.  During 
convalescence  tonics,  like  iron,  quinin,  and  arsenic,  and  a 
liberal  diet  are  necessary. 

Local  Treatment. — In  mild  cases  the  joints  may  be  painted 
with  iodin  and  wrapped  in  cotton-wool.  In  severe  cases 
small  blisters  are  of  great  utility. 

Among  other  effective  remedies  may  be  mentioned  methyl 
salicylates  or  oil  of  gaultheria  (undiluted  on  compresses) ; 
guaiacol  (with  equal  parts  of  glycerin) ;  lead-water  and  lau- 
danum (ice-cold  or  hot),  and  chloroform  liniment.  An 
ointment  of  salicylic  acid  is  often  very  useful : 

R.     Acidi  salicylici      ^^iss 

Olei  terebinth inae f^j 

Adipis  benzoinati q.  s.  ^^ij. 

SiG. — Spread  on  lint  and  keep  in  place  by  means  ot  a  flannel 
binder. 

No  matter  what  local  remedy  is  selected,  it  is  highly  im- 
portant that  the  affected  joints  should  be  kept  at  complete 
rest.  This  may  be  accomplished  by  means  of  padded  splints 
and  a  roller  bandage. 

Lingering  swelling  will  often  yield  to  an  ointment  of  mer- 
cury and  belladonna,  with  firm  strapping  of  the  articulation. 
Blisters  are  also  useful.  When  the  effusion  is  very  great 
and  persistent,  it  may  be  necessary  to  aspirate  the  joint. 

For  the  stiffness  of  the  joints  massage,  warm  baths,  and 
inunctions  with  an  ointment  of  iodin  will  be  found  useful. 
The  hot-air  treatment  also  does  good  in  some  cases. 


CHRONIC  ARTICULAR   RHEUMATISM.  343 

CHRONIC  ARTICULAR  RHEUMATISM. 

Ktiology. — Chronic  articular  rheumatism  nearly  always 
begins  as  a  chronic  affection.  Heredity,  advanced  years,  and 
habitual  exposure  to  cold  and  wet  are  predisposing  factors. 
It  rarely  results  from  an  acute  attack. 

Pathology. — The  fibrous  structures  around  the  joint  are 
greatly  thickened,  so  that  in  long-standing  cases  the  move- 
ments are  restricted ;  the  neighboring  muscles  are  wasted 
from  disuse ;  and  the  nerves  often  reveal  evidences  of 
neuritis. 

Symptoms. — Pain,  stiffness,  deformity,  and  creaking  of 
the  joints  are  the  usual  phenomena.  Several  joints  are  com- 
monly affected,  and  the  disease  shows  no  predilection  for  any 
particular  joint.  The  symptoms  grow  worse  on  the  ap- 
proach of  stormy  weather,  and  at  such  times  exacerbations 
are  liable  to  occur,  in  which  the  joints  become  swollen  and 
tender.     The  duration  is  indefinite. 

Prognosis. — Generally  unfavorable.  Much  relief  may 
follow  persistent  and  judicious  treatment,  but  perfect  cure  is 
rarely  attainable. 

Treatment. — Especial  attention  should  be  given  to  the 
hygiene,  particularly  as  regards  diet,  bathing,  clothing,  exer- 
cise, and  occupation.  A  change  of  residence  to  a  dry,  warm, 
and  equable  climate  is  always  desirable. 

Hot  sulphur  and  hot  saHne  baths  are  often  very  useful. 
Tonics  and  certain  alteratives,  such  as  cod-liver  oil,  iron, 
arsenic,  guaiac,  and  potassium  iodid  are  the  most  generally 
useful  internal  remedies  : 

Ij^ .    Liquoris  potassii  arsenitis f^J^y 

Potassii  iodidi 5'j~"j 

Syrupi  sarsaparillse  compositi  ,  q.  s.  f3iij- — M. 

SiG. — A  teaspoonful  in  water  three  times  a  day  after  meals. 

Local  Treatment. — Massage,  if  employed  systematically, 
often  accomplishes  much  good.  Superheated  air-baths  are 
occasionally  useful.  Electricity  is  of  little  value.  Rubefacient 
liniments  have  a  palliative  influence  in  mild  cases.  An  oint- 
ment of  mercury,  belladonna,  and  ichthyol,  well  rubbed  into 
the  affected  part,  is  sometimes  very  efficacious.     When  the 


344  CONSTITUTIONAL   DISEASES. 

pain  is  severe  and  persistent,  blisters  or  light  applications  of 
the  actual  cautery  prove  effective. 

OTHER  MANIFESTATIONS  OF  RHEUMATISM. 

Muscular  Rheumatism  (Myalgia;  Myodynia). — An 

affection  of  the  voluntary  muscles,  characterized  \^y  pain, 
tenderness,  and  rigidity. 

Types. — Different  names  have  been  applied  according  to 
the  location,  namely :  Torticollis,  or  wry-neck,  when  it  in- 
volves the  sternocleidomastoid  muscles ;  lumbago^  when  it 
involves  the  lumbar  muscles ;  pleurodynia,  when  it  involves 
the  intercostals ;  and  cephalodynia,  when  it  involves  the  oc- 
cipitofrontalis. 

Etiology. — The  gouty  or  rheumatic  diathesis  is  a  predis- 
posing cause.  Exposure  to  cold  and  wet  or  muscular  strain 
usually  excites  it. 

Symptoms. — Pain  is  the  chief  symptom ;  it  is  made  worse 
by  use  of  the  muscles,  and  is  associated  with  tenderness 
which  is  especially  marked  at  the  tendinous  origins  and  in- 
sertions of  the  muscles.  Sometimes  the  muscles  are  con- 
tracted and  rigid ;  this  is  particularly  the  case  in  torticollis, 
or  wry-neck. 

Torticollis. — The  head  is  fixed  and  inclined  to  one  side ; 
every  effort  to  turn  it  is  attended  with  sharp  pain. 

Lumbago. — There  is  a  dull,  aching  pain  across  the  loins. 
Turning  the  body  or  rising  from  the  sitting  posture  causes 
an  exacerbation,  which  is  sometimes  so  severe  that  the  patient 
cries  out.  Care  must  be  taken  to  distinguish  it  from  renal 
calculus,  Pott's  disease,  aneurysm,  perinephritis,  and  uterine 
or  ovarian  disease. 

Pleurody?tia. — The  pain  is  felt  in  the  side,  and  is  increased 
by  deep  breathing,  coughing,  or  twisting  the  body.  There 
is  diffuse  tenderness  to  the  touch.  The  absence  of  fever 
and  of  physical  signs  will  serve  to  distinguish  it  from 
pleurisy. 

The  absence  of  tender  spots  where  the  nerves  make  their 
exit  from  the  muscular  coverings,  the  fact  that  the  pain  does 
not  follow  closely  the  distribution  of  the  nerves,  and  that  the 


OTHER   MANIFESTATIONS   OF  RHEUMATISM.        345 

pain  is  increased  by  movement,  will  serve  to  distinguish 
pleurodynia  from  intercostal  neuralgia. 

Cephalodynia. — This  is  characterized  by  a  superficial  pain 
in  the  head,  increased  by  moving  the  scalp.  It  is  often  asso- 
ciated with  tenderness  on  pressure. 

Prognosis. —  Favorable  under  judicious  and  persistent 
treatment. 

Treatment. — In  mild  cases  it  will  suffice  to  put  the  affected 
muscles  at  rest.  In  pleurodynia  this  is  accomplished  best  by 
strapping  the  affected  side  as  in  fracture  of  the  ribs,  and  in 
lumbago  by  applying  a  large  piece  of  adhesive  plaster  from 
the  floating  ribs  to  the  iliac  crests.  In  more  severe  cases  it 
will  be  necessary  to  apply  rubefacient  liniments,  sinapisms, 
or,  better  still,  hot  fomentations,  and  to  administer  a  saHcy- 
late,  combined,  perhaps,  with  phenacetin  : 

R.    Salophen ^ij 

Acetphenetidini 3J. — M. 

Fiant  chartulse  No.  xij. 

SiG. — One  every  three  hours. 

A  blister  is  occasionally  required.  When  the  pain  is  in- 
tense, intramuscular  injections  of  morphin  (^  grain)  with 
atropin  (y-J-q  grain)  will  afford  great  relief  In  lumbago, 
acupuncture  sometimes  yields  excellent  results.  Hot  packs 
and  baths  are  often  efficacious,  but  great  care  must  be  ex- 
ercised to  guard  against  exposure  after  their  use.  Persistent 
myalgia  is  often  very  favorably  affected  by  massage  and 
applications  of  the  faradic  current.  In  chronic  cases  potas- 
sium iodid  and  guaiac  should  be  tried.  Gelsemium  in  large 
doses  (Brunton)  and  ammonium  chlorid  (Ringer,  Roberts, 
DaCosta)  have  also  been  recommended. 

Neural  Manifestation. — Rheumatism  appears  to  be  a 
frequent  cause  of  neuritis. 

Rheumatic  Affections  of  Mucous  Membranes. — It 
must  be  borne  in  mind  that  pharyngitis,  tonsillitis,  laryngitis, 
and  bronchitis  are  sometimes  dependent  upon  a  rheumatic 
diathesis. 

Rheumatic  Affections  of  Serous  Membranes. — 
Endocarditis,  pericarditis,  pleuritis,  iritis,  and  meningitis  may 
be  excited, by  rheumatism. 


L 


34^  CONSTITUTIONAL  DISEASES. 

Cutaneous  Manifestations. — Purpura,  urticaria,  and 
erythema  nodosum  are  sometimes  associated  with  rheu- 
matism. 

GOUT^ 
(Podagra.) 

Definition. — A  disturbance  of  metaboHsm,  character- 
ized in  its  typical  form  by  deposits  of  sodium  biurate  in  the 
joints  and  other  structures,  and  by  recurrent  attacks  of 
arthritis. 

i^tiology. — Gout  most  frequently  develops  in  the  third 
and  fourth  decades.  It  is  more  common  in  males  than  in 
females.  It  is  often  hereditary.  The  excessive  use  of  wines 
or  malt  liquors,  overeating,  sedentary  habits,  nervous  strain, 
and  chronic  lead-poisoning  are  predisposing  factors. 

Pathology. — The  pathology  of  gout  is  still  obscure.  It 
is  generally  conceded  that  the  disease  is  in  some  way  asso- 
ciated with  an  excess  of  uric  acid  compounds  in  the  blood ; 
but  whether  these  compounds  are  the  sole  cause  of  the  con- 
stitutional disturbances,  and  whether  the  excess  in  the  blood 
is  due  to  increased  formation  or  diminished  excretion,  or 
both,  are  questions  that  await  solution. 

The  only  distinctive  anatomic  lesions  of  gout  are  those  of 
the  joints.  These  consist  of  deposits  of  sodium  biurate 
(tophi)  in  the  cartilages  and  fibrous  tissues  and  secondary 
inflammatory  changes.  In  long-continued  cases  the  joints 
become  irregularly  enlarged  and  stiff.  Ultimately  ulcera- 
tion of  the  superficial  tissues  may  ensue,  with  the  discharge 
of  the  uratic  concretion.  The  small  joints  of  the  feet  and 
hands  are  usually  the  first  to  be  affected,  but  subsequently 
other  joints,  like  those  of  the  ankles,  wrists,  and  elbows, 
become  involved.  Uratic  deposits  are  often  found  also 
along  the  tendons,  in  the  external  ear,  in  the  nose,  and  in 
various  other  parts. 

In  acute  cases  the  affected  joint,  most  frequently  the 
metatarsophalangeal  of  the  great  toe,  is  intensely  hyper- 
emic,  swollen,  and  edematous. 

Chronic  interstitial  nephritis,  arteriosclerosis,  and  hyper* 
trophy  of  the  heart  are  important  concomitant  lesions. 


GOUT.  347 

Clinical  Varieties. — (i)  Articular  gout,  which  may  be 

acute  or  chronic;  (2)  non-articular  or  irregular  gout. 

Symptoms. — Acute  Gout. — The  attack  is  usually  pre- 
ceded by  certain  prodromes — restlessness,  insomnia,  morose- 
ness,  irritability,  dyspepsia,  and  changes  in  the  urine,  this 
secretion  being  scanty,  high-colored,  and  deficient  in  urates. 
The  arthritic  phenomena  usually  appear  suddenly  in  the 
early  morning  hours,  and  are  characterized  by  pain  and 
swelling  in  the  ball  of  the  great  toe.  The  affected  joint  is 
so  tender  that  the  slightest  pressure  causes  agony.  It  is  of 
a  reddish-purple  color ;  its  surface  is  glazed  ;  and  the  neigh- 
boring veins  are  full  and  distinct.  During  the  paroxysm 
the  temperature  is  moderately  elevated  (ioi°-i02°  F.)  and 
the  pulse  quickened.  Toward  daylight  the  pain  subsides 
to  a  great  extent  and  the  patient  falls  asleep.  During 
the  day  he  is  comparatively  comfortable,  but  there  are 
severe  exacerbations  for  several  successive  nights.  At  first 
the  attacks  may  be  a  year  apart,  but  as  they  multiply  the 
interval  grows  less,  until  finally  the  patient  is  seldom  en- 
tirely free  from  suffering. 

Retrocedent  Gout. — This  term  is  applied  to  a  condition  in 
which  the  arthritic  phenomena  suddenly  subside  and  grave 
gastric,  cardiac,  or  cerebral  symptoms  follow. 

Chronic  Gout. — The  joints  are  affected  one  by  one,  and 
become  stiff,  irregularly  enlarged,  and  deformed.  Chalk- 
stones,  or  tophi,  sometimes  ulcerate  their  way  through  the 
skin  and  are  discharged.  Similar  deposits  are  frequently 
found  along  the  tendons  and  in  the  helix  of  the  ear. 

Constitutional  symptoms  similar  to  those  occurring  in 
non-articular  or  irregular  gout  are  more  or  less  conspicuous. 

Non-articular  Gout  (Uric  Acid  Diathesis  ;  Latent  Gout ;  Gouti- 
ness ;  Lithemia). — This  form  of  gout  is  more  often  met  with 
in  America  than  the  articular  variety.  It  presents  the  follow- 
ing clinical  features : 

G astro-intestinal  Phenomena. — The  tongue  is  generally 
coated  and  the  breath  heavy;  the  appetite  is  variable:  some- 
times it  is  lost,  at  others  it  is  inordinate ;  acid  eructations, 
heart-burn,  and  flatulence  are  frequent  gastric  symptoms. 

Uri?iary  Phenomena. — The  urine  is  scanty,  high-colored, 


348  CONSTITUTIONAL   DISEASES. 

of  high  specific  gravity  (1025  to  1035),  and  on  standing 
throws  down  an  abundant  brick-dust  sediment.  The  solids 
render  the  urine  irritating,  so  that  dull  aching  in  the  loins 
and  burning  in  the  penis  after  micturition  are  common 
symptoms.  A  trace  of  sugar  is  sometimes  detected  on 
chemical  examination.  The  urine  often  stains  the  clothes 
red. 

Circulatory  Phenomena. — These  consist  in  increased  arterial 
tension,  accentuation  of  the  second  aortic  sound,  and  a 
tendency  to  arteriosclerosis. 

Nervous  Phenomena. — These  are  extremely  varied,  and 
include  headache,  vertigo,  disturbed  sleep,  tinnitus  aurium, 
depression  of  spirits,  failure  of  memory,  loss  of  energy, 
irritability,  and  neuralgic  pain  in  various  parts  of  the  body. 

Complications  and  Sequelae. — These  include :  Chronic 
interstitial  nephritis,  arteriosclerosis,  hypertrophy  of  the 
heart,  angina  pectoris,  apoplexy,  chronic  bronchitis,  and  cer- 
tain cutaneous  affections — chronic  eczema,  urticaria,  and 
psoriasis. 

Diagnosis. — Acute  Rheumatism. — This  more  commonly 
affects  the  larger  joints  ;  it  is  markedly  migratory ;  it  is 
associated  with  higher  fever  and  more  copious  perspiration  ; 
and  it  shows  far  greater  tendency  to  endocardial  and  peri- 
cardial inflammations. 

Rheumatoid  Arthritis. — This  occurs  more  frequently  in 
women  than  in  men  ;  it  is  more  likely  to  begin  in  the  fingers 
than  in  the  toes  ;  it  usually  involves  symmetric  joints.  It  is 
more  apt  to  involve  the  spinal  and  temporomaxillary  joints; 
it  causes  more  deformity  and  fixation  of  the  joints,  and, 
finally,  it  is  not  associated  with  tophaceous  deposits  in  the 
joints  or  other  tissues,  nor  necessarily  with  arterial  or  renal 
complications. 

Prognosis. — Acute  gout  rarely  proves  fatal ;  recurrence, 
however,  is  to  be  expected.  On  account  of  the  tendency  to 
arterial  and  renal  complications,  the  prognosis  of  chronic  j 
gout,  when  the  disease  is  fairly  established,  should  be  some- 
what guarded.  It  is  largely  proportionate  to  the  mildness 
by  the  symptoms  and  the  extent  to  which  the  patient  can  be 
controlled. 


GOUT.  349 

Treatment. — The  Acute  Attack. — The  best  remedy  is 
colchicum :  lO  to  20  drops  of  the  wine  well  diluted  should 
be  given  every  two  hours,  and  stopped  as  soon  as  the  symp- 
toms subside.  Alkalis  are  valuable  adjuncts.  The  free  use 
of  water  should  be  encouraged.  Constipation  should  be 
relieved  by  a  full  dose  of  blue-mass  or  a  saline  draft.  Opium 
or  phenacetin  may  be  required  for  the  relief  of  the  pain. 
The  affected  part  should  be  elevated  and  wrapped  in  cotton- 
wool, or  covered  with  warm  fomentations  or  with  cloths 
soaked  in  lead-water- and  laudanum.  The  diet  should  be 
light  and  non-stimulating. 

Chronic  Gout. — As  regards  diet,  simplicity  and  modera- 
tion are  of  the  utmost  importance.  Generally  speaking,  a 
diet  composed  for  the  most  part  of  milk,  farinaceous  foods, 
succulent  vegetables,  eggs,  fish,  is  most  suitable.  The  foods 
most  likely  to  disagree  are  veal,  liver,  sweetbreads,  hashes, 
croquettes,  concentrated  soups,  vegetables  rich  in  nucleins, — 
peas  and  beans, — pastry,  sweets,  coffee,  malt  liquors,  and 
heavy  wines.  Some  patients  are  exceedingly  intolerant  of 
acid  fruit. 

Water-drinking  between  meals  should  be  encouraged.  No 
more  should  be  eaten  than  is  absolutely  necessary  to  satisfy 
hunger.  The  patient  should  be  warmly  clothed  and  should 
avoid  as  far  as  possible  exposure  to  sudden  atmospheric 
changes.  Systematic  exercise  in  the  open  air  is  extremely 
beneficial.  When  active  exercise  is  not  feasible,  massage 
may  be  strongly  recommended.  All  overwork  of  mind 
should  be  forbidden.  Hydrotherapy — tepid  sponge-baths 
and  douches — is  useful.  Heavy,  robust  patients  often  derive 
much  benefit  from  the  Turkish  bath.  Visits  to  certain  min- 
erals springs — Bedford,  Saratoga,  Harrowgate,  Carlsbad, 
Contrexeville,  Aix-les-Bains — are  sometimes  of  great  value. 
,  Free  action  of  the  bowels  should  be  secured.  The  occa- 
sional use  of  calomel  or  blue-mass  at  night,  with  a  saline  in 
the  morning,  is  often  of  value.  Among  the  special  remedies 
advocated  for  gout  may  be  mentioned  alkalis  and  alkaline 
mineral  waters,  colchicum,  guaiac,  arsenic,  and  iodids. 

Of  these,  the  alkalis,  especially  the  vegetable  salts  of  potas- 
sium or  lithium,  are  the  most  useful.     Colchicum  is  most 


3 so  CONSTITUTIONAL   DISEASES. 

effective  in  the  acute  paroxysms,  although  small  doses  with 
alkalis  may  be  of  benefit  in  the  interval.  Guaiac  prob- 
ably ranks  next  in  efficacy  to  the  alkalis.  The  prolonged 
use  of  arsenic  in  small  doses  seems  to  be  of  some  value, 
lodids  are  sometimes  of  service  in  relieving  the  concomi- 
tants and  sequels  of  gout,  but  have  little,  if  any,  effect  upon 
the  disease  itself  Salicylates  relieve  pain,  but  are  distinctly 
inferior  to  colchicum. 

Chronic  affections  of  the  joints  are  best  treated  by  gentle 
massage,  friction,  and  warm  sulphur  baths. 

RHEUMATOID  ARTHRITIS. 

(Arthritis  Deformans;  Rheumatic  Gout.) 

Definition. — A  chronic  affection  of  the  joints,  character- 
ized by  destruction  of  the  cartilages,  new  osseous  forma- 
tions, immobility,  and  deformity. 

!^tiolog"y. — It  develops  most  frequently  in  the  third  and 
fourth  decades.  Women  are  much  more  often  attacked 
than  men.  Heredity,  prolonged  mental  strain,  and  enfee- 
blement  of  health  from  bad  hygienic  environment,  poor 
food,  or  prolonged  lactation  are  predisposing  factors. 

Pathology. — The  origin  of  rheumatoid  arthritis  is  ob- 
scure. Some  regard  it  as  a  trophoneurosis,  allied  to  the 
arthropathies  met  with  in  certain  diseases  of  the  spinal  cord. 
Others  believe  it  to  be  infectious. 

The  cells  of  the  cartilages  and  of  the  synovial  membrane 
proliferate  and  lead  to  villous  or  nodular  outgrowth,  which 
may  subsequently  be  transformed  into  osteophytes.  The 
central  portions  of  the  cartilages  ultimately  wear  away  and 
leave  the  bones  exposed.  The  heads  of  the  bones  become 
smooth,  hard,  and  shiny.  The  periarticular  tissues  are  also 
thickened.  The  deformity  leads  to  stiffness  and  ankylosis. 
Subluxations  are  common.  The  surrounding  muscles  are 
generally  atrophied.     All  joints  are  liable  to  be  affected. 

Symptoms. — It  may  be  either  acute  or  chronic,  the 
latter  being  the  more  common  form.  In  the  acute  form 
several  joints  are  simultaneously  involved ;  they  become 
swollen,  painful,  and  tender,  but  rarely  reddened.     There  is 


RHEUMATOID  ARTHRITIS.  35  I 

moderate  fever.  The  symptoms  soon  subside,  to  reappear, 
however,  at  frequent  intervals. 

In  the  chronic  form  the  hands,  particularly  the  metacar- 
pophalangeal joints,  are  usually  first  affected ;  then  the 
wrists,  knees,  toes,  jaws,  and  spine.  Symmetric  joints  are 
usually  attacked.  The  symptoms  are  swelling,  pain,  immo- 
bility, and  deformity.  The  joints  are  stiff  and  creak  when 
moved ;  later  complete  ankylosis  develops.  The  muscles 
waste,  and  contractures  increase  the  deformity. 

In  advanced  cases  the  fingers  are  bent  backward,  often 
locked,  and  turned  toward  the  ulnar  side ;  the  thighs  are 
drawn  up;  the  legs  are  adducted  and  flexed.  The  patient 
may  be  a  helpless  invalid  for  many  years. 

Heberden' s  Nodes. — These  are  small  nodules  that  develop 
gradually  on  the  sides  of  the  distal  phalanges,  especially  of 
the  fingers.  At  times  they  may  be  sHghtly  painful  and 
tender.  They  are  usually  seen  in  middle-aged  women. 
They  are  usually  regarded  as  an  expression  of  rheumatoid 
arthritis. 

Diagnosis. — The  differential  diagnosis  between  rheu- 
matoid arthritis  and  gout  has  already  been  considered  (see 
p.  348). 

Chronic  Rheumatism.— This  usually  involves  fewer  joints; 
it  attacks  especially  the  larger  joints  ;  it  very  rarely  involves 
the  spinal  or  temporomaxillary  joints  ;  it  does  not  cause  en- 
largement of  the  ends  of  the  bones ;  it  shows  greater  ten- 
dency to  involve  the  heart;  and  it  is  less  steadily  progres- 
sive. 

Prognosis. — Unfavorable.  Sometimes  the  disease  is 
local  and  remains  in  one  joint  (monoarticular  form).  Gen- 
erally, however,  several  joints  are  affected,  and  while  judi- 
cious and  persistent  treatment  may  retard  the  progress  of 
the  disease,  a  cure  is  rarely  attainable. 

Treatment. — Hygienic  treatment  is  most  important. 
Tonics,  especially  iron,  arsenic,  and  cod-liver  oil,  are  gen- 
erally required.  Salicylates  are  sometimes  of  service  in 
acute  exacerbations.  Massage  is  valuable  in  preserving  the 
mobility  of  the  joints  and  in  maintaining  the  nutrition  of  the 
muscles. 


352  CONSTITUTIONAL   DISEASES. 

RICKETS. 

(Rachitis.) 

Definition. — A  constitutional  disease  of  early  childhood, 
characterized  chiefly  by  defective  nutrition  of  the  osseous 
structures. 

!^tiolog"y. — Rickets  is  rarely  congenital ;  it  usually  de- 
velops between  the  first  and  second  years.  Poverty,  arti- 
ficial feeding,  and  bad  hygienic  conditions  are  the  predis- 
posing causes. 

Pathology. — The  most  marked  changes  are  observed 
in  the  long  bones  and  ribs.  The  cartilaginous  lamina  be- 
tween the  epiphysis  and  the  shaft  are  considerably  thick- 
ened, and  are  spongy  and  irregular  in  outline;  microscopic 
examination  reveals  an  excessive  proliferation  of  the  carti- 
lage cells,  with  scanty  calcification.  The  periosteum  is 
thickened  and  highly  vascular,  and  when  stripped  off,  soft, 
porous  bone  is  exposed.  The  bones  are  soft,  being  ex- 
tremely deficient  in  lime-salts  ;  when  ossification  finally  re- 
sults, the  bones  become  heavy,  large,  and  irregular  in  out- 
line ;  these  changes  correspond  to  the  clinical  phenomena — 
bow-legs,  knock-knees,  spinal  curvature,  pigeon-breast,  and 
square  cranium. 

The  liver  and  spleen  are  often  considerably  enlarged. 

Symptoms. — The  early  symptoms  are :  Restlessness 
and  slight  fever  at  night ;  free  perspiration  about  the  head  ; 
diffuse  soreness  and  tenderness  of  the  body ;  pallor  ;  slight 
diarrhea;  enlargement  of  the  liver  and  spleen  ;  delayed  den- 
tition, and  the  eruption  of  badly  formed  teeth. 

Skeletal  Phe^iomena. — The  head  is  large  and  more  or  less 
square  in  outline;  careful  palpation  may  detect  soft  areas. 
The  sides  of  the  thorax  are  flattened ;  the  sternum  is  promi- 
nent ;  nodules  can  be  felt  at  the  sternal  ends  of  the  ribs — 
"  rachitic  rosary  " ;  there  may  be  a  distinct  transverse  groove 
at  the  level  of  the  ensiform  cartilage  ;  the  spinal  column  is 
frequently  curved  anteroposteriorly  or  laterally ;  the  long 
bones  are  curved  and  prominent  at  their  extremities. 

Complications. — These  include  :  Green-stick  fractures, 


DIABETES.  353 

convulsions,  laryngismus  stridulus,  paresis  of  the  extremi- 
ties, and  acute  pulmonary  disease. 

Treatment. — The  general  nutrition  must  be  improved 
by  placing  the  child  under  the  best  hygienic  conditions. 
When  hand-feeding  becomes  necessary,  fresh  cow's  milk, 
properly  modified  to  suit  the  age  of  the  infant,  egg-albumen, 
and  fresh  meat-juice  should  be  recommended.  Cod-liver 
oil  is  a  valuable  nutrient  tonic.  Syrup  of  the  iodid  of  iron 
(3  to  20  drops  thrice  daily)  is  indicated  when  there  is 
anemia. 

Ijl..    Olei  morrhuse f^iss 

Olei  sassafras 

Pulveris  acaciae 

Pulveris  sacchari      aa  q.  s. 

Syrupi  ferri  iodidi f^ij-iv 

Aquae q.  s.  ad  f^iij. — M. 

SiG. — A  teaspoonful  to  a  dessertspoonful  after  meals. 

Phosphorus  (5  to  15  minims  of  the  official  elixir  thrice 
daily)  is  regarded  as  being  especially  efficacious  by  many 
authorities.     It  may  be  added  to  the  cod-liver  oil. 

DIABETES. 

(Diabetes  Mellitus.) 

Definition. — Ajiutritional  disease,  characterized  by  the 

persistent  presence  of  sugar  in  the  urine,  polyuria,  and  loss 
of  flesh  and  strength. 

Btiology. — The  disease  occurs  most  frequently  between 
the  ages  of  thirty  and  sixty.  It  is  much  more  common  in 
males  than  in  females.  Hebrews  appear  to  be  especially 
prone  to  it.  Heredity,  overeating,  sedentary  habits,  and 
prolonged  mental  anxiety  are  predisposing  factors. 

Pathology.— ^The  condition  which  is  really  responsible 
for  diabetes  is  still  undetermined.  Puncture  of  the  floor  of 
the  fourth  ventricle  will  produce  glycosuria,  but  the  cases 
are  rare  in  which  lesions  of  this  region  have  been  found 
after  death. 

In  a  large  number  of  cases  macroscopic  or  microscopic 
lesions   are  found  in    the  pancreas.     It   has  been    shown, 

23 


354»  CONSTITUTIONAL   DISEASES. 

however,  by  Opie  and  others,  that  diabetes  is  absent  in  pan- 
creatic disease  unless  the  lesions  are  such  as  destroy  the 
islands  of  Langerhans.  Cirrhotic  and  degenerative  changes 
are  frequently  found  in  the  liver.  The  kidneys  are  com- 
monly the  seat  of  hyperemia  and  catarrhal  inflammation. 

According  to  Lepine  and  others,  the  disease  is  due  to  the 
accumulation  of  glucose  in  the  blood,  owing  to  the  absence 
of  a  sugar-splitting  ferment  (glycolytic  ferment)  which  the 
pancreas  normally  manufactures.  In  the  present  state  of 
our  knowledge,  however,  pancreatic  disease  cannot  be 
assumed  in  all  cases.  It  may  be  that  the  hyperglycemia  in 
some  instances  results  from  a  failure  of  the  liver  (owing  to 
actual  disease  or  to  functional  disturbances  induced  by 
influences  emanating  from  the  central  nervous  system)  to 
store  up  or  to  retain  the  carbohydrates. 

Symptoms. —  Urinary  Phenomena. — The  urine_  Js_  in- 
creased in  quantity,  the  amount  varying  from  three  or  four 
pints  to  as  many  quarts ;  its  color  is  pale  ;  its  specific  grav- 
ity usually  ranges  from  1030  to  1050;  it  has  a  sweetish 
taste  and  an  aromatic  odor.  In  summer  it  attracts  flies  and 
rapidly  ferments.  It  may  leave  a  whitish  residue  on  the 
clothes.  The  percentage  of  glucose  varies  from  0.5  per 
cent,  to  10  per  cent. 

General  Phenomeita. — There  is  loss  of  flesh  and  strength; 
the  temperature  is  normal  or  subnormal ;  the  appetite  is 
often  inordinate,  and  the  thirst  unquenchable  ;  the  tongue 
is  often  fissured  and  beefy  red ;  the  bowels  are  usually  con- 
stipated. The  muscles  are  sometimes  the  seat  of  painful 
cramps. 

Cutaneous  Phenomena. — The  skin  is  harsh  and  dry,  and 
frequently  the  seat  of  intense  itching.  Pjmritusjs  especially 
observed  at  the  genitalia,  and  this  may  be  the  first  subjec- 
tive symptom. 

Nej^vous  Phenomejta. — These  are  :  Headache,  depression 
of  spirits,  diminished  or  lost  patellar  reflexes,  impaired  sex- 
ual power,  dimness  of  vision,  and  neuralgia. 

The  duration  varies  from  a  few  weeks  in  the  acute  form 
to  many  years  in  the  chronic  form. 


DIABETES.  355 

Complications. — These  include  :  Pulmonary  tubercu- 
losis ;  pneumonia ;  gangrene  of  the  lung ;  defective  vision 
from  soft  cataract,  retinitis,  or  atrophy  of  the  optic  nerve; 
cutaneous  lesions,  as  boils,  eczema,  carbuncles,  and  gan- 
grene; nephritis;  neuritis,  and  diabetic  coma,  or  aceto- 
nemia. 

This  last  condition  is  characterized  by  epigastric  pain, 
dyspnea,  a  fruity  odor  of  the  breath,  headache,  delirium, 
stupor,  and  coma.  It  is  believed  to  be  due  to  the  presence 
in  the  blood  of /9-oxybutyric  acid. 

Diagnosis. — Care  must  be  taken  to  distinguish  simple 
glycosuria  from  diabetes.  The  former  is  recognized  by  being 
transient,  and  unassociated  with  the  constitutional  symptoms 
of  diabetes. 

Pruritus  and  apparently  causeless  loss  offlesh  and  strength 
should  lead  to  a  suspicion  of  diabetes. 

Prognosis. — The  younger  the  patient,  the  stronger  the 
hereditary  tendency,  the  larger  the  amount  of  sugar  ex- 
creted, the  less  the  glycosuria  can  be  controlled  by  diet 
alone,  the  graver  the  prognosis.  On  the  other  hand,  when 
it  occurs  after  middle  life  in  association  with  a  gouty  diathe- 
sis, and  the  glycosuria  is  not  pronounced,  the  prognosis 
for  a  long  duration  is  comparatively  favorable.  Absolute 
cure  is  rarely  attainable. 

Treatment. — Dietetic  Treatment. — Sugars  and  starches 
must  be  restricted.  Since  the  patient's  appetite  is  often  in- 
ordinate, it  is  necessary  also  to  regulate  the  quantity  and 
character  of  the  foods  that  are  recognized  as  admissible. 
The  following  foods  may  be  Included  in  the  dietary: 

Animal  Foods. — Meats  of  various  kinds  (except  liver), 
game,  light  broths  and  soups,  fish,  and  eggs. 

Vegetables. — Celery,  lettuce,  cauliflower,  tomatoes,  mush- 
rooms, string-beans,  young  onions,  olives,  water-cress,  and 
spinach. 

Beverages. — Buttermilk,  skim  milk,  sour  wines  (Rhine 
wines),  carbonated  waters,  and  coffee  and  tea  without  sugar. 

Relishes. — Nuts  of  all  kinds  (except  chestnuts),  cream 
cheese,  and  pickles. 

Bread. — Bread  made  of  gluten,  bran  flour,  or  almond 


356  CONSTITUTIONAL   DISEASES. 

flour.  It  should  be  borne  in  mind  that  all  the  gluten  flours 
are  rich  in  starch. 

Fruits. — Cranberries,  sour  cherries,  limes,  lemons,  and  red 
currants. 

Substitutes  for  Sugar. — Saccharin  and  glycerin. 

The  following  foods  should  be  avoided :  Liver,  oysters, 
wheat  bread,  biscuits,  pastry,  potatoes,  beets,  carrots,  peas, 
turnips,  parsnips,  sweet  fruits,  rice,  barley,  tapioca,  corn- 
starch, corn-meal,  chocolate,  cocoa,  syrups,  preserves,  and 
most  liquors. 

Hygienic  Treatment. — Fresh  air  and  systematic  exercise 
are  of  great  value.  The  patient  must  be  warned,  however, 
against  overexertion.  Flannel  should  be  worn  next  to  the  skin, 
and  all  undue  exposure  avoided.  Hydrotherapy  is  decidedly 
efiicacious.  Diabetics  who  still  possess  a  fair  measure  of 
health  frequently  derive  much  benefit  from  a  visit  to  certain 
mineral  springs,  such  as  Neuenahr,  Homburg,  Carlsbad,  and 
Vichy. 

Medicinal  Treatment. — Tonics,  like  arsenic,  strychnin,  and 
cod-liver  oil,  are  often  indicated.  Opium  is  generally  the 
most  reliable  special  remedy;  it  should  be  given  in  small 
doses  gradually  increased  until  the  patient  takes  5  or  6 
grains  daily.  Codein  (|  grain  increased  to  6  grains  a  day) 
is  sometimes  preferable  to  opium.  Salicylic  compounds  rank 
next  in  efficacy  to  opium.  From  40  to  60  grains  of  am- 
monium or  strontium  salicylate  may  be  given  in  twenty-four 
hours. 

R.    Strontii  salicylatis 5'V-vj 

Liquoris  potassii  avsenitis f::^j 

Glycerini ,  f^j 

Aquae  cinnamomi q.  s.  ad  f^iv. — M. 

SiG. — Dessertspoonful  thrice  daily. 

Alkaline  carbonates  and  alkaline  mineral  waters  have  long 
enjoyed  a  reputation.  Bromids  are  useful  in  subduing  ner- 
vous symptoms.  Among  remedies  that  occasionally  succeed 
may  be  mentioned  Clemens's  solution  of  arsenic  bromid 
(3  to  5  minims);  antipyrin  (8  to  10  grains  thrice  daily);  and 
jambul. 


DIABETES  INSIPIDUS.  35/ 

Diabetic  coma  is  always  fatal,  but  inhalations  of  oxygen 
or  the  subcutaneous  injection  of  large  quantities  of  normal 
saline  solution  at  intervals  may  give  a  few  hours'  respite,  in 
which  consciousness  returns. 

DIABETES  INSIPIDUS, 

Definition. — A  chronic  condition,  characterized  by  the 
excretion  of  large  quantities  of  pale,  limpid  urine  of  low 
specific  gravity  and  free  from  albumin  and  sugar. 

The  condition  must  be  distinguished  from  the  polyuria 
observed  in  chronic  interstitial  nephritis  and  in  some  cases 
of  hysteria. 

Etiology. — It  is  most  common  between  the  ages  of 
twenty  and  thirty.  More  males  are  affected  than  females. 
Heredity  is  an  important  etiologic  factor.  It  is  sometimes 
associated  with  lesions  in  the  neighborhood  of  the  medulla 
or  floor  of  the  fourth  ventricle,  such  as  tumors,  hemor- 
rhages, and  especially  syphilitic  basilar  meningitis.  In  a 
few  cases  it  appears  to  have  followed  intense  emotional  ex- 
citement. 

Pathology. — Little  is  known  of  the  pathology.  The 
kidneys  are  frequently  enlarged  and  congested,  and  the 
ureters  dilated. 

The  theory  which  is  generally  accepted  as  accounting  for 
the  polyuria  is  that  it  is  due  to  a  vasomotor  paresis  of  the 
renal  vessels,  which  permits  a  free  transudation  of  liquid. 

Symptoms. — The  disease  may  begin  insidiously  or  ab- 
ruptly ;  the  latter  is  the  rule.  77//?  urinp :  The  quantity_is_ 
increased,  often  as  much  as  eight  or  ten  quarts  being  ex- 
creted in  the  twenty-four  hours  ;  it  is  pale,  and  resembles 
water;  it  has  a  specific  gravity  of  1002  to  1005.  The  total 
amount  of  solids  is  not  diminished.  Albumin  and  sugar  are 
generally  absent,  though  there  may  be  a  trace  of  the  latter. 

The  most  important  general  symptoms  are  extreme  thirst ; 
dryness  of  the  skin ;  constipation ;  mental  apathy ;  and  ex- 
aggeration of  the  knee-jerks.  In  many  cases  there  is  neither 
weakness  nor  emaciation.     Complications  are  rare. 

Diag^nosiS. — The  high  specific  gravity  of  the  urine  and 


358  CONSTITUTIONAL  DISEASES. 

the  presence  of  sugar  will  serve  to  distinguish  diabetes  mel- 
litus  from  diabetes  insipidus. 

Interstitial  nephritis  may  be  recognized  by  the  presence  of 
tube-casts  in  the  urine,  the  albuminuria,  and  cardiovascular 
signs. 

Prognosis. — The  duration  of  the  disease  is  very  indefi- 
nite. Not  infrequently  spontaneous  cure  occurs.  Unless 
the  result  of  a  serious  nervous  lesion,  it  rarely  terminates 
fatally. 

Treatment. — No  benefit  is  derived  from  restricting  the 
quantity  of  water  desired.  Acidulated  drinks,  like  lemonade, 
aid  in  assuaging  thirst.  Many  remedies  have  been  recom- 
mended; those  possessing  the  most  extended  reputation  are 
opium  (4  to  8  grains  a  day),  valerian  (^  to  i  fluidounce  of 
ammoniated  tincture  daily),  ergot  [\  to  i  dram  of  the  extract 
daily),  antipyrin  (10  grains  thrice  daily),  and  gallic  acid 
(i  dram  a  day).  Galvanism — one  pole  applied  to  the  neck 
and  the  other  to  the  loins — has  been  recommended.  Tonics 
— cod-liver  oil,  iron,  and  strychnin — are  sometimes  required. 
In  syphilitic  cases  good  results  not  infrequently  follow  the 
use  of  antiluetic  remedies. 

SCURVY. 

(Scorbutus.) 

Definition. — A  disease  characterized  by  marked  weak- 
ness, anemia,  hemorrhages  from,  the  mucous  membranes  and 
into  the  skin,  and  a  tendency  to  a  spongy  state  of  the  gums. 

etiology. — The  chief  predisposing  causes  of  scurvy  in 
adults  are  unhygienic  surroundings  and  a  dietary  deficient 
in  fresh  vegetables. 

Symptoms. — These  include  anemia  with  great  weakness 
and  lassitude ;  spongy,  bleeding  gums  with  fetor  of  the 
breath  and  loosening  of  the  teeth  ;  subcutaneous  ecchymoses 
and  hemorrhages  from  the  mucous  membranes  ;  and  brawny 
induration  of  the  muscles  in  various  parts  of  the  body  from 
a  sanguineous  transudation. 

An  infantile  form  of  scurvy  (Barlow's  disease)  sometimes 
follows  the  prolonged  use  of  condensed  milk,  steriHzed  milk, 


HEMOPHILIA.  359 

or  proprietary  foods.  The  characteristic  symptoms  are  : 
Pallor,  tenderness  or  pain  in  the  legs  or  back  on  handling, 
slight  swelling,  especially  about  the  diaphyses,  immobility  of 
the  legs  (pseudoparalysis),  ecchymoses,  and  hematuria. 
The  gums  are  usually  affected  when  there  are  teeth,  but 
very  rarely  when  there  are  no  teeth. 

Prognosis. — Favorable  in  its  earlier  stages. 

Treatment. — The  diet  should  include  fresh  vegetables- 
potatoes,  lettuce,  cabbage,  and  onions — with  several  ounces 
of  lemon-juice  daily.  Iron  is  of  service.  The  mouth  should 
be  cleansed  at  frequent  intervals  with  some  antiseptic  wash. 

In  infantile  scurvy  good  results  follow  the  use  of  fresh 
milk,  beef-juice,  and  orange -juice. 

HEMOPHILIA* 

(Bleeder's  Disease ;  Hemorrhagic  Diathesis.) 

Definition. — A  hereditary  disease,  characterized  by  a 
tendency  to  bleed  excessively  from  slight  wounds  or  even 
spontaneously. 

!^tiology. — The  chief  cause  is  heredity.  It  is  more  com- 
mon in  males,  but  it  is  generally  transmitted  by  females,  even 
by  those  who  are  not  themselves  afflicted. 

Pathology. — The  exact  cause  of  the  hemorrhages  is  un- 
known. In  a  few  instances  the  walls  of  the  vessels  have 
been  found  unnaturally  thin  and  degenerated. 

Symptoms. — The  chief  symptom  is  free  and  persistent 
bleeding  after  trivial  injury.  Spontaneous  hemorrhages  from 
mucous  membranes  of  the  nose,  stomach,  bowel,  etc.,  and 
subcutaneous  extravasations  are  also  quite  common.  The 
only  other  symptom  is  a  peculiar  inflammation  of  the 
joints,  resembling  rheumatism. 

Prognosis. — Unfavorable.  Grandidier  states  that  one- 
half  die  before  the  eighth  year,  and  less  than  one-eighth 
survive  their  twenty-first.  In  some  instances  the  tendency 
is  outgrown. 

Treatment. — This  is  chiefly  protective  and  palliative. 
Bleeding  will  call  for  rest,  the  application  of  cold  compresses 
and  of  styptics,  and  the  administration  of  internal  hemo- 


360  CONSTITUTIONAL   DISEASES. 

Statics.     The  drugs  most  worthy  of  confidence  are  gelatin, 
calcium  chlorid,  and  thyroid  extract. 

PURPURA  HAEMORRHAGICA* 

(Morbus  Maculosus  Werlhofii.) 

Definition. — A  disease  arising  without  obvious  cause, 
and  characterized  by  extravasation  of  blood  into  the  sub- 
cutaneous tissues  and  bleeding  from  the  mucous  membranes. 

j^tiology. — The  cause  is  unknown.  An  infectious  origin 
is  not  unhkely.  The  disease  occurs  most  frequently  in  young 
adults,  especially  in  debilitated  girls. 

Symptoms. — The  onset  may  be  marked  by  moderate 
fever  (102°  to  103°  F.),  headache,  malaise,  and  pain  in  the 
limbs  ;  but  these  symptoms  may  be  absent,  and  the  disease 
ushered  in  with  a  copious  purpuric  eruption,  followed  by 
bleeding  from  the  mucous  membranes.  Anemia  and  its 
associated  phenomena  develop  in  severe   cases. 

Diagnosis. — Scurvy  is  to  be  distinguished  by  a  history 
of  dietetic  errors ;  by  the  spongy  state  of  the  gums ;  and  by 
the  brawny  induration  of  the  muscles.  Hemophilia  may  be 
recognized  by  the  family  history  and  the  tendency  to 
arthritis. 

Prognosis. — This  depends  on  the  severity.  Mild  cases 
recover  in  from  one  to  two  weeks  ;  severe  cases  may  prove 
fatal  in  a  few  days  from  exhaustion  or  from  hemorrhage  into 
the  brain.     Relapses  are  not  uncommon. 

Treatment. — The  patient  should  be  put  to  bed  and 
placed  upon  a  nourishing  diet.  Among  the  many  remedies 
advocated  ergot,  turpentine,  tincture  of  ferric  chlorid,  calcium 
chlorid,  and  gelatin  enjoy  the  most  favor. 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


DISTURBANCES  OF  MOTION. 

These  consist,  for  the  most  part,  of  loss  of  power  or 
paralysis,  and  manifestations  of  motor  excitation,  such  as 
convulsions,  choreiform  movements,  and  tremors. 

Paralysis. — The  paralysis  may  be  irregularly  distributed, 
or  it  may  involve  a  single  member,  when  it  is  termed  mono- 
plegia ;  a  lateral  half  of  the  body,  when  it  is  termed  hemi- 
plegia ;  or  the  body  from  the  waist  down,  when  it  is  termed 
paraplegia. 

Irregular  paralysis  may  result  from  : 

1.  Disseminated  lesions  in  the  motor  areas  of  the  brain, 
which  are  commonly  syphilitic. 

2.  Lesions  in  the  basal  ganglia, — pons,  crura  cerebri, 
medulla, — when  it  is  often  associated  with  headache,  vom- 
iting, vertigo,  and  optic  neuritis. 

3.  Acute  poliomyelitis.  This  develops  abruptly  ;  it  occurs 
in  young  children ;  and  it  is  followed  by  rapid  improvement 
in  some  muscles  and  permanent  atrophy  and  paralysis  in 
others. 

4.  Chronic  poliomyelitis.  This  develops  in  middle  life ; 
begins  in  the  small  muscles  of  the  nand ;  is  associated  with 
atrophy,  and  progresses  very  slowly. 

5.  Muscular  dystrophies.  These  commonly  develop 
during  childhood ;  involve  the  muscles  of  the  calves,  trunk, 
face,  or  shoulder-girdle ;  are  associated  with  progressive 
atrophy ;  and  are  generally  traceable  to  heredity. 

6.  Multiple  neuritis.  This  is  recognized  by  the  history, 
pain,  disturbances  of  sensation^  and  tenderness  over  the 
nerve-trunks. 

361 


362  DISEASES   OF   THE   NERVOUS  SYSTEM. 

7.  Syringomyelia.  This  is  rare,  develops  during  ado- 
lescence, and  is  recognized  by  lateral  spinal  curvature, 
fibrillary  tremors,  atrophy  of  the  affected  muscles,  various 
trophic  disturbances,  and  a  loss  of  thermic  and  painful  sen- 
sations, while  tactile  sensation  is  retained. 

Monoplegia  may  result  from  : 

1.  A  focal  lesion  in  the  cortical  area  of  the  brain.  This 
may  be  recognized  by  the  history,  the  absence  of  wasting, 
of  sensory  disturbances,  and  of  the  reactions  of  degenera- 
tion. 

2.  A  lesion  of  the  peripheral  nerve,  from  traumatism,  neu- 
ritis, or  the  pressure  of  a  tumor.  Brachial  monoplegia  fre- 
quently results  from  the  pressure  of  the  head  on  the  arm 
during  sleep.  Monoplegia  of  peripheral  origin  is  recognized 
by  the  history,  the  wasting,  the  sensory  disturbances,  and 
the  presence  of  reactions  of  degeneration. 

3.  Hysteria.  This  may  be  recognized  by  the  history,  sex, 
and  temperament ;  the  paroxysmal  character  of  the  paraly- 
sis ;  the  disturbances  of  sensation  ;  and  contractures  without 
atrophy  or  electric  disturbances. 

Facial  monoplegia  may  result  from  a  small  lesion  in  the 
facial  center  of  the  cortex  or  in  the  medulla ;  or  from  in- 
volvement of  the  nerve  in  the  canal  of  the  temporal  bone  ; 
or  after  its  exit  from  the  stylomastoid  foramen. 

Facial  diplegia  (double  facial  paralysis)  generally  results 
from  a  lesion  at  the  base  of  the  brain. 

Hemiplegia  may  result  from : 

1.  A  diffuse  lesion  of  the  motor  cortex.  The  paralysis  is 
on  the  opposite  side  of  the  body  and  is  unassociated  with 
anesthesia. 

2.  A  lesion  of  the  internal  capsule  or  the  adjacent  ganglia 
(corpus  striatum  and  optic  thalamus).  This  is  the  most 
common  seat  of  hemorrhage  ;  the  paralysis  is  on  the  oppo- 
site side  of  the  body  and  is  rarely  associated  with  anesthesia. 

3.  A  lesion  of  the  crus  cerebri.  This  frequently  produces 
hemiplegia  and  hemianesthesia  on  the  opposite  side,  and 
paralysis  of  the  oculomotor  nerve  on  the  side  of  the  lesion, 
indicated  by  dilated  pupil,  strabismus,  and  ptosis. 


DISTURBANCES   OF  MOTION.  363 

4.  A  lesion  of  the  pons.  This  frequently  produces  hemi- 
plegia and  hemianesthesia  on  the  opposite  side,  and  facial 
paralysis  on  the  side  of  the  lesion. 

5.  A  unilateral  lesion  high  in  the  cord  (very  rare).  This 
produces  a  spastic  paralysis  on  the  side  affected,  and  hemianes- 
thesia on  the  opposite  side  ("  Brown-Sequard's  paralysis  "). 

6.  Hysteria.  This  may  be  recognized  by  the  history,  sex, 
and  temperament ;  by  being  frequently  paroxysmal ;  by  its 
association  with  sensory  disturbances ;  by  the  absence  of 
wasting  and  of  abnormal  electric  reactions  ;  and  by  the 
escape  of  the  facial  muscles. 

Paraplegia  may  result  from  : 

1.  Hemorrhage  into  the  cord  at  the  dorsal  region.  The 
paralysis  develops  abruptly,  and  is  associated  with  complete 
anesthesia  and  involvement  of  the  bladder  and  rectum. 

2.  Hemorrhage  into  the  membranes  of  the  cord.  The 
paralysis  develops  rapidly,  but  more  slowly  than  the  preced- 
ing ;  is  associated  with  intense  tearing  pains  and  incomplete 
anesthesia. 

3.  Some  forms  of  multiple  neuritis.  This  may  be  recog- 
nized by  the  pains,  the  disturbances  of  sensation,  the  tender- 
ness over  the  nerve-trunks,  and  the  absence  of  "  girdle  pain  " 
and  sphincter  involvement. 

4.  Fracture  of  the  vertebrae. 

5.  Acute  myelitis.  The  paralysis  develops  in  the  course 
of  a  few  days,  and  is  associated  with  anesthesia,  bed-sores, 
involvement  of  the  bladder  and  rectum,  loss  of  reflexes,  and 
wasting  of  the  muscles. 

6.  Landry's  disease  (acute  ascending  paralysis).  This  de- 
velops in  the  course  of  a  few  days,  and  is  un associated  with 
anesthesia,  wasting  of  the  muscles,  bed-sores,  or  sphincter 
involvement. 

7.  Chronic  myelitis.  This  develeps  over  several  years, 
and  is  associated  with  numbness  and  tingHng,  increased 
reflexes,  involvement  of  the  bladder  and  rectum,  and  anes- 
thesia. 

8.  Compression  of  the  cord  from  morbid  growths,  aneu- 
rysm, or  spinal  caries.       This  may  be  recognized  by  the  his- 


364  DISEASES   OF  THE  NERVOUS  SYSTEM. 

tory,  the  symptoms  of  the  primary  disease,  the  anesthesia 
or  hyperesthesia,  and  the  intense  pains  radiating  along  the 
Hne  of  the  spinal  r^erves. 

9.  Lateral  sclerosis.  This  develops  slowly  and  is  asso- 
ciated with  a  spastic  condition  of  the  muscles  and  with  in- 
creased reflexes,  and  lacks  sensory  disturbances. 

10.  Injury  of  the  brain  in  delivery  (spastic  paraplegia  of 
infants).  The  symptoms  resemble  lateral  sclerosis,  and  are 
often  associated  with  imbecility  or  idiocy. 

11.  Hysteria.  This  may  be  recognized  by  the  history, 
sex,  and  temperament ;  by  being  frequently  paroxysmal ; 
and  by  the  absence  of  wasting  and  of  abnormal  electric  re- 
actions. 

12.  Caisson  disease  (divers*  paralysis).  The  history  will 
establish  the  diagnosis. 

Convulsions. — A  convulsion  is  a  condition  in  which 
there  are  excessive  muscular  contractions,  continued  or  in- 
termittent, dependent  upon  an  involuntary  discharge  of 
motor  impulses  from  the  nerve-centers. 

Intermittent  contractions  are  termed  clonic ;  continued 
contractions,  tonic. 

Convulsions  may  be  general  or  local.  The  term  spasm  is 
sometimes  applied  to  the  latter. 

Varieties  of  Convulsions. — Three  varieties  are  frequently 
made:  (i)  Epileptiform;  (2)  tetanic ;  (3)  hysterical. 

Epileptiform  Convulsions. — In  this  form  there  is  uncon- 
sciousness, and  the  movements  are  for  the  most  part  clonic. 
Epileptiform  convulsions  may  result  from  : 

1.  Idiopathic  epilepsy.  This  condition  usually  develops 
before  the  age  of  twenty-five,  and  the  convulsions  are  gen- 
eral and  are  unassociated  with  any  definite  cause. 

2.  Organic  brain  disease.  In  this  condition  there  may  be 
a  history  of  syphilis  or  of  injury;  the  convulsions  may  be 
local,  or  begin  as  such  and  become  general ;  and  there  may 
be  concomitant  symptoms  of  cerebral  disease. 

3.  Toxic  agents  in  the  blood.  Alcoholism,  the  infectious 
fevers,  and  uremia  are  frequently  associated  with  convulsions. 

4.  Reflex  irritation.     Such   convulsions   are   usually  ob- 


DISTURBANCES   OF  MOTION.  365 

served  in  young  children,  and  result  from  gastric  irritation, 
an  adherent  prepuce,  intestinal  parasites,  or  teething. 

5.  Cerebral  anemia.  Such  convulsions  are  sometimes 
seen  after  profuse  hemorrhage,  in  fatty  heart,  and  in  poison- 
ing from  cardiac  paralyzants  like  aconite  and  veratrum 
viride.    ' 

Eclampsia. — This  term  is  applied  to  a  sudden  attack  of 
convulsions,  the  result  of  a  temporary  cause,  such  as  the 
convulsions  of  childhood  resulting  from  reflex  irritation,  and 
the  convulsions  of  pregnancy  resulting  from  toxic  materials 
retained  in  the  blood. 

Tetanic  Convulsions. — In  this  form  the  discharges  emanate 
from  the  spinal  cord,  and  are  not  associated  with  a  loss  of 
consciousness.  Tetanic  convulsions  may  result  from  : 
R  I.  Tetanus.  This  may  be  recognized  by  the  history  of  a 
wound,  the  tonic  character  of  the  convulsions,  the  early  in- 
volvement of  the  jaw,  and  the  absence  of  fever. 

2.  Spinal  meningitis.  This  may  be  recognized  by  the 
exquisite  pain  in  the  back,  Kernig's  sign,  disturbances  of 
sensation,  fever,  and  late  involvement  of  the  jaw. 

3.  Strychnin-poisoning.  This  may  be  recognized  by  the 
history,  the  intermittent  character  of  the  convulsions,  the 
absence  of  fever,  and  the  escape  of  the  muscles  of  the  jaw 
until  very  late. 

4.  Tetany.  In  this  condition  the  extremities  are  chiefly 
involved ;  the  convulsions  are  intermittent,  and  can  be  pro- 
duced by  pressure  on  the  nerves  and  arteries  of  the  affected 
limbs. 

Hysteric  Convulsions. — These  are  manifestations  of 
hysteria,  and  in  them  consciousness  is  only  partially  or 
apparently  lost.  They  are  not  preceded  by  an  aura,  but 
sometimes  by  a  sen'sation  as  of  a  ball  in  the  throat — the  "  glo- 
bus hystericus";  the  eyes  are  partially  closed;  conscious- 
ness is  not  actually  lost ;  the  face  is  often  expressive  of 
some  emotion ;  the  tongue  is  not  bitten  ;  the  movements 
are  usually  tonic,  and  if  clonic,  appear  purposive;  and  the 
paroxysm  is  of  long  duration. 

Local  Convulsions  or  Spasms. — Spasm  of  the  face  may  re- 
sult from — (i)  A  cortical  lesion  in  the  inferior  portion  of  the 


366  DISEASES   OF   THE   NERVOUS  SYSTEM. 

ascending  frontal  convolution  ;  (2)  from  tic  convulsif — a  con- 
dition occurring  in  young  children  affecting  the  facial  and 
neighboring  muscles,  and  associated  with  mimicry,  a  ten- 
dency  to  repeat  vulgar  phrases,  and  various  mental  disturb- 
ances ;  (3)  from  habit  (habit  chorea) ;  and  sometimes  from 
(4)  tic  doiiloiireiix — neuralgia  of  the  fifth  nerve. 

Temporary  spasms  of  one  arm  or  one  leg  are  usually  mani- 
festations of  Jacksonian  epilepsy  (focal  epilepsy),  but  they 
sometimes  result  from  hysteria. 

Spasm  of  the  hand  developing  when  the  member  is  put  to 
use  may  result  from  writers'  cramp,  Thomsen's  disease,  or 
hysteria. 

Spasm  of  the  cervical  muscles  (wry-neck,  torticollis)  may 
result  from  congenital  shortening  of  the  sternomastoid, 
myalgia,  hysteria,  caries  of  the  vertebrae,  or  the  irritation  of 
enlarged  cervical  glands. 

Spasms  of  the  larynx,  esophagus,  and  diaphragm  (hiccup) 
have  already  been  discussed. 

Saltatory  Spasm. — This  term  is  employed  to  designate  a 
condition  allied  to  hysteria,  in  which  a  violent  spasm  seizes 
the  muscles  of  the  leg  as  soon  as  the  feet  touch  the  ground, 
and  as  a  result  the  patient  is  thrown  violently  into  the  air. 

Salaam  Convulsions. — These  consist  of  violent  paroxysmal 
bobbing  movements  of  the  head  or  trunk,  and  may  be  asso- 
ciated with  hysteria,  chorea,  or,  rarely,  organic  brain  disease. 
,  Choreiform  Movements. — These  are  coarse,  jerky, 
irregular,  involuntary  movements  which  more  or  less  simu- 
late purposive  movements.     They  may  result  from  : 

1.  Acute  chorea  (St.  Vitus's  dance).  This  disease  is  seen 
in  children  ;  is  usually  mild  ;  runs  a  course  of  several  weeks  ; 
and  is  prone  to  be  followed  by  endocarditis. 

2.  Chorea  insaniens.  A  grave  disease  occurring  in  adults, 
especially  pregnant  women,  and  characterized  by  violent 
movements,  delirium,  and  fever. 

3.  Huntingdon's  chorea  (chronic  chorea).  An  affection 
occurring  in  adult  life,  generally  hereditary,  and  character- 
ized by  irregular  movements,  disturbance  of  speech,  and  in- 
creasing dementia. 

4.  Organic   brain    disease.     Choreiform   movements   are 


DISTURBANCES   OF  MOTION.  367 

frequently  observed  in  cerebral  palsies  of  children  ;  they  may 
also  develop  on  one  side  of  the  body  before  an  attack  of 
apoplexy  (prehemiplegic  chorea),  or  in  the  paralyzed  mem- 
bers after  the  hemorrhage  (posthemiplegic  chorea). 

5.  Peripheral  irritation.  Choreiform  movements  some- 
times develop  in  pregnancy,  and  are  occasionally  noted  in 
stumps  after  amputation. 

6.  Habit.  Children  frequently  acquire,  through  constant 
repetition  or  mimicry,  choreiform  movements  which  may 
last  indefinitely. 

7.  Hysteria.  The  marked  rhythmic  character  of  the 
movements  and  the  history  will  aid  in  the  recognition  of 
hysteric  chorea. 

%'  8.  Disseminated  cerebrospinal  sclerosis.  This  disease 
usually  induces  tremors,  but  not  uncommonly  the  move- 
ments are  choreiform.  The  increased  reflexes,  the  nystag- 
mus, the  loss  of  power,  the  spastic  gait,  and  the  impairment 
of  intellect  will  aid  in  its  recognition. 

9.  Paramyoclonus  multiplex.  A  very  rare  disease,  of 
unknown  origin,  characterized  by  violent  clonic  spasms  of 
the  muscles  of  the  trunk  and  upper  part  of  the  limbs.  The 
spasms  are  bilateral  and  rarely,  if  ever,  involve  the  forearms, 
hands,  legs,  or  feet.  They  occur  only  at  intervals  and  can 
usually  be  brought  on  by  irritation  of  the  skin  or  tendons,  or 
by  excitement. 

Athetosis.— This  term  was  employed  by  Hammond  to 
designate  certain  movements  occurring  chiefly  in  the  hands 
and  feet,  and  characterized  by  slow  twisting,  intertwining, 
separation,  and  extension  of  the  fingers  and  toes.  Athetosis 
is  frequently  observed  in  the  cerebral  palsies  of  children, 
and  it  occasionally  occurs  in  adults  as  a  result  of  lesions  in 
the  basal  ganglia. 

Tremors. — A  tremor  is  a  fine  vibratory  movement  due 
to  the  alternate  contraction  and  relaxation  of  antagonistic 
muscles.    Tremors  are  observed  in  the  following  conditions : 

1.  They  may  exist  from  birth  unassociated  with  other 
symptoms. 

2.  They  may  depend  upon  a  lowered  tone  of  the  nervous 
system,  being  frequently  observed  in  exophthalmic  goitre, 
neurasthenia,  and  in  the  convalescence  from  acute  disease. 


368  DISEASES   OF   THE   NERVOUS  SYSTEM. 

3.  They  may  be  toxic,  resulting  from  alcoholism  or  mer- 
curial poisoning. 

4.  They  may  be  due  to  old  age. 

5.  They  are  frequently  a  symptom  of  organic  disease  of 
the  brain  and  cord ;  as  such,  they  are  met  with  in  paretic 
dementia,  and  especially  in  disseminated  sclerosis. 

6.  They  may  be  the  chief  symptom  in  paralysis  agitans. 

7.  They  may  be  hysterical. 

The  Gait. — The  Ataxic  Gait. — In  locomotor  ataxia  the 
patient  raises  the  foot  high,  throws  it  forward,  and  brings  it 
down  suddenly,  so  that  the  whole  sole  comes  in  contact  with 
the  floor  at  once. 

Spastic  Gait. — In  spastic  paraplegia  the  movements  are 
stiff,  the  knees  come  together,  the  leg  drags  behind,  and  the 
toe  catches  the  ground. 

Festination. — This  term  is  applied  to  the  gait  of  advanced 
paralysis  agitans ;  in  walking,  the  body  inclines  more  and 
more  forward,  and  the  steps  grow  faster  and  faster  until  the 
patient  falls,  straightens  himself  by  a  supreme  effort,  or  finds 
support  in  some  neighboring  object. 

Steppage  Gait. — In  chronic  multiple  neuritis  the  patient 
raises  the  foot  high,  turns  the  toe  up,  and  brings  the  heel 
down  first. 

The  Gait  of  Pseudomuscular  Hypertrophy. — The  feet  are 
wide  apart,  the  belly  protrudes,  and  the  movements  are 
clumsy  and  waddling. 

Titubation. — This  term  is  applied  to  the  peculiar  gait  ob- 
served in  lesions  of  the  cerebellum.  It  resembles  the  gait 
of  locomotor  ataxia,  but  is  much  more  staggering,  the  body 
swaying  like  that  of  a  person  intoxicated.  With  the  ataxia 
there  is  a  marked  vertigo,  which  usually  disappears  when 
the  patient  lies  down. 

The  Reflexes. — The  Knee-jerk,  or  Patellar  Tendon  Reflex. 
— This  is  obtained  by  tapping  the  quadriceps  tendon  between 
its  insertion  and  the  patella  while  the  leg  is  crossed  over  its 
fellow. 

The  knee-jerk  is  increased  in  the  following  conditions  :  '\ 

I.  In  brain  lesions  which  abolish  the  inhibitory  influence 
of  the  cerebrum,  as  in  hemiplegia  from  apoplexy,  tumor,  etc. 


DISTURBANCES   OF  MOTION:  369 

2.  In  compression  or  partial  destruction  of  the  cord  above 
the  lumbar  region,  as  in  Pott's  disease  or  tumor  of  the  cord. 

3.  In  disseminated  cerebrospinal  sclerosis,  lateral  sclerosis, 
and  amyotrophic  lateral  sclerosis. 

4.  In  irritability  of  the  cord,  as  in  mania,  hysteria,  strych- 
nin-poisoning, and  spinal  meningitis. 

Tlie  knee-jerk  is  diminished  or  absent  in  the  following  con- 
ditions : 

1.  In  the  various  forms  of  primary  muscular  atrophy. 

2.  In  lesions  of  the  nerves  which  cut  off  the  impulse  from 
the  cord — as  neuritis. 

3.  In  lesions  of  the  posterior  columns  of  the  cord,  as  in 
locomotor  ataxia. 

4.  In  poliomyelitis,  both  acute  and  chronic. 

5.  In  advanced  myelitis,  when  the  cord  is  sufficiently 
injured. 

6.  In  exhaustion  of  the  spinal  centers,  as  after  prolonged 
muscular  exertion. 

7.  In  some  cases  of  complete  division  of  the  spinal  cord, 
as  by  fracture  or  luxation  of  the  vertebra:^. 

Ankle-clonus. — This  consists  of  vibratory  movements  of 
the  foot,  obtained  by  supporting  the  tendo  Achillis  with  one 
hand  while  the  foot  is  strongly  flexed  with  the  other.  It  is 
rarely  obtainable  in  health ;  it  is  marked  in  primary  lateral 
sclerosis  and  cerebral  hemiplegia,  and  is  occasionally  pres- 
ent in  hysteria. 

Arm-jerk. — This  is  obtained  by  striking  the  biceps  tendon 
at  the  elbow,  or  the  triceps  tendon  above  the  olecranon. 

Jaw-jerk. — This  is  obtained  by  tapping  the  jaw  while  the 
mouth  is  partially  open. 

Babinski's  Reflex. — This  consists  in  extension  of  the  great 
toe  instead  of  flexion  when  the  sole  of  the  foot  is  tickled. 
It  is  often  normally  present  in  infants.  In  adults  it  is  sug- 
gestive of  some  disturbance  of  the  pyramidal  tracts — menin- 
gitis, tumor,  hemorrhage,  amyotrophic  lateral  sclerosis,  etc. 

Kernig's  Sign. — This  consists  in  an  inability  to  straighten 
the  leg  completely  when  the  patient  is  in  the  recumbent  pos- 
ture and  the  thigh  is  flexed  at  a  right  angle  with  the  pelvis. 
It  is  of  value  in  the  diagnosis  of  meningitis. 
24 


370  DISEASES   OF  THE  NERVOUS  SYSTEM. 

The  Cutaneous  or  Superficial  Reflexes. — These  are  muscular 
contractions  resulting  from  irritation  of  the  sensory  nerves 
of  the  skin.  Their  nature  is  imperfectly  understood.  As 
they  are  inconstant  in  health  they  are  much  less  serviceable 
for  diagnosis  than  the  deep  reflexes.  Cutaneous  reflexes 
are  frequently  lost  in  those  diseases  in  which  the  tendon  re- 
flexes are  exaggerated.  The  important  reflexes  of  this  type 
are  the  following : 

Abdominal  Reflex. — Tickling  or  shaking  the  skin  of  the 
abdomen  causes  contraction  of  the  muscles  on  the  side 
stimulated. 

Cremasteric  Reflex. — Stroking  the  inner  side  of  the  thigh 
causes  retraction  of  the  testicle. 

Plantar  Reflex. — Tickling  the  sole  of  the  foot  causes  sud- 
den plantar  flexion  of  the  toes. 

Glnteal  Reflex. — Irritation  of  the  skin  about  the  buttock 
causes  contraction  of  the  gluteal  muscles. 

DISTURBANCES  OF  SENSATION* 

These  consist  chiefly  in  a  loss  of  sensation — anesthesia ; 
increased  sensation — Jiyperesthesia  ;  certain  abnormal  sensa- 
tions— paresthesicE  ;  and  subjective  painful  sensations — neu- 
ralgias. 

Anesthesia. — Ordinaiy  cutaneous  sensibility  may  be 
tested  by  the  prick  of  a  pin,  by  a  pinch,  or  by  the  faradic 
current. 

Anesthesia  results  from  interruption  of  the  sensory  tract 
in  the  nerves,  as  by  neuritis  ;  from  interruption  of  the  sensory 
tract  in  the  cord  or  brain ;  from  organic  disease  of  the  sensory 
area  of  the  brain  ;  from  the  action  of  toxic  substances  on 
the  nerves  or  centers  ;  from  certain  functional  conditions  like 
hysteria ;  and  from  reflex  irritation. 

Hemianesthesia. — A  loss  of  sensation  in  a  lateral  half  of 
the  body.     It  may  result  from  : 

I.  Hysteria.  This  is  often  unassociated  with  paralysis  of 
motion,  and  may  be  recognized  by  the  history,  sex,  and 
temperament  of  the  patient;  by  the  paroxysmal  character 
of  the  anesthesia;  and  by  exclusion  of  other  causes. 


DISTURBANCES   OF  SENSATION.  37  I 

2.  A  unilateral  lesion  high  in  the  cord.  This  is  very  rare, 
and  may  be  recognized  by  being  associated  with  hemiplegia 
on  the  opposite  side. 

3.  A  lesion  of  the  medulla  (very  rare).  The  hemianes- 
thesia is  usually  associated  with  hemiplegia,  paralysis  of  the 
cranial  nerves,  difficult  swallowing,  and  cardiac  and  respira- 
tory disturbances. 

4.  A  lesion  in  the  pons.  The  hemianesthesia  is  often 
associated  with  hemiplegia  on  the  same  side  and  facial  palsy 
on  the  opposite  side. 

5.  A  lesion  in  the  crus  or  peduncle.  The  hemianesthesia 
is  often  associated  with  hemiplegia  on  the  same  side  and 
paralysis  of  the  oculomotor  nerve  on  the  opposite  side. 

6.  A  lesion  of  the  posterior  limb  of  the  internal  capsule 
or  of  the  optic  thalamus  pressing  on  the  capsule. 

7.  A  lesion  of  the  cortex  immediately  back  of  the  fissure 
of  Rolando  (posterior  central  convolution). 

Monanesthesia. — A  loss  of  sensation  in  one  member.  It 
may  result  from  hysteria,  from  a  focal  lesion  of  the  sensory 
area  of  the  cortex,  or  from  a  lesion  of  the  nerves  supplying 
the  member. 

Paranesthesia. — A  loss  of  sensation  in  all  parts  below 
the  waist.  It  may  result  from  hysteria,  organic  diseases  of 
the  cord,  neuritis  of  the  lower  extremities,  or  reflex  irri- 
tation. 

Thermo-anesthesia. — Insensibility  to  heat  or  cold  occur- 
ring as  an  independent  condition.  It  is  sometimes  observed 
in  hysteria  and  syringomyelia. 

Analgesia. — Insensibility  to  pain.  It  is  sometimes  ob- 
served in  hysteria  and  in  certain  organic  diseases  of  the 
spinal  cord,  especially  syringomyelia. 

Astereognosis. — A  loss  of  the  power  of  recognizing  ob- 
jects by  touch  or  a  failure  of  tactile  memory.  It  is  a  symp- 
tom of  disease  in  the  sensory  area  of  the  cortex  (middle  third 
of  the  posterior  central  convolution  and  adjacent  part  of  the 
inferior  parietal  lobule). 

Retardation  of  Sensations. — This  is  frequently  observed  in 
all  forms  of  anesthesia,  but  especially  in  the  anesthesia  of 
locomotor  ataxia. 


372  DISEASES   OE   THE   NERVOUS  SYSTEM. 

The  Sense  of  Space. — The  distance  at  which  two 
points  of  contact  can  be  recognized  as  two  points.  Nor- 
mally the  distance  varies  in  different  parts  and  in  different 
individuals. 

On  the  cheek  it  is  11-15  millimeters. 

On  the  forehead,  22  millimeters. 

On  the  forearm,  40  millimeters. 

On  the  chest,  45  millimeters. 

On  the  thigh  and  upper  arm,  68  millimeters. 

On  the  leg,  40  millimeters. 

On  the  palm  of  the  hand,  8-12  millimeters. 

On  the  back  of  the  hand,  31  millimeters.' 

Hyperesthesia  is  increased  insensibility  to  external  im- 
pressions. 

It  is  commonly  observed  in  hysteria,  especially  in  con- 
nection with  the  joints,  breasts,  genitalia,  and  spine.  It  is 
also  observed  in  neurasthenia  and  in  beginning  inflamma- 
tion of  the  nerves  and  of  the  cerebrospinal  meninges. 

Paresthesia. — This  term  is  used  to  indicate  certain  dis- 
agreeable subjective  phenomena,  such  as  numbness,  tingling, 
itching,  creeping,  prickling,  etc. 

Paresthesia  is  observed  in  many  conditions,  as  hysteria, 
spinal  sclerosis,  neurasthenia,  and  injury  or  inflammation  of 
the  nerves.  It  is  frequently  observed  in  elderly  persons 
with  arteriosclerosis. 

Girdle  Sensation. — The  sense  of  having  a  girdle  or  tight 
band  around  the  trunk.  It  is  frequently  observed  in  spinal 
sclerosis. 

Neuralgia. — This  consists  of  paroxysms  of  severe  pain 
radiating  along  the  line  of  the  nerve-trunks.  The  pain  is 
relieved  by  pressure,  but  there  are  tender  spots  \points 
douloureux)  where  the  nerve  makes  its  exit  from  bony  canals 
or  muscular  coverings. 

Lightni7ig -pains. — This  term  is  applied  to  the  sharp  lanci- 
nating pains  observed  in  locomotor  ataxia.  They  usually 
occur  in  the  extremities,  and  may  be  mistaken  for  rheuma- 
tism. 

Causalgia. — This  term  has  been  applied  by  S.  Weir 
Mitchell  to  an  intensely  burning  sensation  generally  observed 
in  "  glossy  skin." 


DISTURBANCES   OF  NUTRITION.  373 

Pressure  Sense. — By  this  sense  the  amount  of  pressure 
exerted  on  a  given  part  of  the  body  is  determined.  It  may 
be  tested  by  placing  upon  the  palms  or  fingers  objects  of 
the  same  bulk  but  of  different  weight,  the  hands  being 
supported  upon  a  table. 

Muscular  Sense. — This  is  the  sense  by  which  weight, 
muscular  effort,  and  position  are  determined.  It  is  often 
defective  in  hysteria,  locomotor  ataxia,  and  in  many  forms 
of  paralysis. 

DISTURBANCES  OF  NUTRITION. 

These  consist  in  atrophy  of  the  m.uscles,  changes  in  elec- 
tremuscular  contractility,  tissue  metamorphoses,  and  in  cer- 
tain abnormalities  of  the  appendages. 

Muscular  Atrophy. — Atrophy  or  wasting  of  the  muscles 
results  from : 

1.  Inactivity.  Cerebral  palsies  may  thus  be  associated 
with  very  gradual  wasting. 

2.  Lesions  of  the  cells  in  the  anterior  gray  horns  of  the 
cord,  as  in  acute  and  chronic  poliomyelitis. 

3.  Lesions  of  the  nerves,  such  as  neuritis  or  traumatism. 

4.  Certain  diseases  of  the  muscles  themselves,  as  the  mus- 
cular dystrophies. 

The  atrophy  that  attends  chronic  affections  of  the  joints 
probably  results  from  neuritis. 

Changes  in  :Electromuscular  Contractility.— A 
normal  response  of  the  muscles  to  both  galvanic  and  faradic 
current  usually  occurs  in  liysteric  paralysis  and  in  paralysis 
of  cerebral  origin.  An  increased  response  to  both  currents 
without  qualitative  change  indicates  a  state  of  hypersens- 
itiveness  of  the  spinal  centers  or  peripheral  nerves,  and  may 
be  observed  in  very  recent  cases  of  ncuritic  paralysis  and  in 
tetany.  A  diminished  response  to  both  currents  without 
qualitative  change  is  observed  in  the  muscular  dystrophies. 

Reaction  of  Degeneration  (DeR). — This  consists  in  a  quali- 
tative change  in  the  electric  reaction,  a  reversal  of  that  oc- 
curring in  normal  muscle.  It  is  obtained  only  with  the 
galvanic  current  when    the    electrode    is    placed    over   the 


374  DISEASES   OE  THE  NERVOUS  SYSTEM. 

muscle^ — not  its  motor  nerve  or  motor  point, — and  occurs 
in  paralyzed  muscles  which  are  in  certain  stages  of  degenera- 
tion owing  to  a  lesion  of  the  ganglion  cells  in  the  anterior 
gray  horns  of  the  cord  or  of  the  prolongations  of  these  cells 
in  the  peripheral  nerves.  Thus  it  is  observed  in  acute  and 
clironic  polioiiiyclitis,  in  acute  myelitis,  and  in  severe  forms  of 
neuritis.  In  these  diseases  the  affected  muscles  fail  to  re- 
spond to  the  faradic  current,  but  still  respond  to  the  gal- 
vanic current.  The  responses,  however,  instead  of  being 
prompt  and  short,  as  in  health,  are  sluggish  and  persistent, 
and,  moreover,  are  reversed  in  their  sequence.  Thus,  the 
anodal  (positive  pole)  closing  contraction  may  equal,  or  at  a 
later  period  exceed,  the  cathodal  (negative  pole)  closing  con- 
traction, and  the  cathodal  opening  contraction  may  equal 
or  exceed  the  anodal  opening  contraction.  These  reactions 
may  be  expressed  as  follows  : 

An  CIC  equals  or  is  greater  than  CaClC.  CaOC  equals 
or  is  greater  than  AnOC. 

Arthropathies. — An  arthropathy  is  a  degenerative  affec- 
tion of  the  joints,  characterized  by  marked  swelling  due  to 
effusion,  erosion  of  the  cartilages,  relaxation  and  calcifica- 
tion of  the  ligaments,  and  atrophy  of  the  heads  of  the 
bones.  Arthropathies  are  observed  in  certain  organic  dis- 
eases of  the  spinal  cord,  more  especially  in  locomotor  ataxia 
and  syringomyelia.  Some  regard  the  joint  phenomena  of 
rheumatoid  arthritis  as  belonging  to  this  class. 

Ulceration  Resulting  from  Perverted  Nutrition. — 
Acute  Dec2ibitus. — This  term  is  applied  to  ulcers  appearing 
in  a  few  hours  or  days,  on  parts  subjected  to  pressure,  after 
the  occurrence  of  a  severe  cerebral  or  spinal  lesion. 

Chronic  Decubitus. — This  term  is  applied  to  the  ulcers 
which  ultimately  appear  on  parts  subjected  to  pressure  in 
the  course  of  chronic  spinal  affections. 

Perforating  Ulcer  of  the  Foot. — This  term  is  applied  to  an 
undermining  ulcer  of  the  foot  most  commonly  observed  in 
locomotor  ataxia.  It  frequently  penetrates  the  deep  struc- 
tures and  involves  the  bones. 

Symmetric  Gangrene  {Raynaud's  Disease). — This  is  a  gan- 
grenous affection  involving  the  fingers,  toes,  tip  of  the  nose, 


DISTURBANCES   OF  CONSCIOUSNESS.  375 

or  ears.  It  arises  spontaneously,  and  is  probably  due  to  a 
vasomotor  spasm. 

Trophic  Affections  of  the  Skin. — Herpes,  scleroderma, 
vitiligo,  chloasma,  and  the  "glossy  skin"  following  injuries 
of  the  nerve-trunks  are  illustrations  of  this  class  of  trophic 
phenomena. 

Trophic  Affections  of  the  Hair  and  Nails. — After  injury  of 
the  nerves  and  in  neuritis  the  nails  often  become  dry,  brittle, 
and  cracked.  Under  similar  conditions  there  may  be  a  loss 
of  hair,  an  overgrowth  of  hair,  or  a  change  in  the  color  of 
the  hair. 


DISTURBANCES  OF  CONSaOUSNESS* 

Coma. — Coma  is  a  state  of  prolonged  unconsciousness, 
somewhat  resembling  sleep,  from  which  the  patient  cannot 
be  aroused. 

Temporary  unconsciousness  due  to  anemia  of  the  brain 
is  termed  syncope.  It  may  be  recognized  by  the  extreme 
pallor,  weak  pulse,  and  feeble  heart-sounds.  Coma  may 
result  from : 

1.  Traumatism. — This  can  be  recognized  only  by  the  his- 
tory or  the  local  evidence  of  injury. 

2.  Organic  Disease  of  the  Brain. — The  most  common 
cause  under  this  head  is  apoplexy,  which  may  be  recognized 
by  the  history,  the  age,  the  condition  of  the  arteries,  and 
by  evidences  of  paralysis,  such  as  stertorous  breathing,  un- 
natural relaxation  or  rigidity  on  one  side  of  the  body,  con- 
jugate deviation  of  the  eyes,  and  a  higher  temperature  in 
one  axilla. 

3.  Epilepsy. — The  coma  of  epilepsy  is  usually  of  short 
duration.  It  may  be  recognized  by  the  history,  by  the 
bloody  saliva,  by  the  presence  of  scars  on  the  tongue  from 
previous  attacks,  and  by  the  exclusion  of  other  causes. 

4.  Tliermic  Fever  {Snn stroke). — -The  temperature  of  the 
day  or  of  the  room  in  which  the  patient  is  found,  the  ex- 
tremely high  body-temperature,  and  the  absence  of  other 
causes  will  usually  prevent  an  error  in  diagnosis. 

5.  Certain  Drtigs. — Under  this  head  come  alcoholism  and 


3/6  DISEASES   OF   THE   NERVOUS  SYSTEM. 

opium-poisoiiing.  In  alcoholism  the  patient  can  generally  be 
aroused  by  shouting  in  the  ear,  there  is  the  odor  on  the 
breath,  and  there  is  an  absence  of  other  causes. 

In  opium- poisoning  the  pupils  are  small,  the  respirations 
are  slow,  the  temperature  is  normal  or  subnormal ;  there 
may  be  the  odor  of  laudanum  on  the  breath.  The  diagnosis 
will  be  aided  by  the  exclusion  of  other  causes. 

6.  Uremia. — In  this  condition  there  is  a  urinous  odor  to 
the  breath ;  the  aortic  second  sound  is  accentuated ;  the 
urine  is  scanty  and  contains  albumin ;  the  temperature  may 
be  above  or  below  normal ;  the  pupils  are  usually  small  and 
equal,  and  there  is  no  evidence  of  other  cause. 

7.  The  Infectious  Fevers. — The  history  is  sufficient  to 
make  the  diagnosis.  Pernicious  malarial  fever  may  produce 
sudden  coma,  and  in  this  condition  the  examination  of  the 
blood  affords  conclusive  evidence. 

8.  Hysteria. — The  history,  age,  and  sex  of  the  patient  and 
the  absence  of  other  cause  will  suggest  the  condition. 

9.  Acetonemia. — Diabetic  coma  may  be  recognized  by  the 
history,  the  sweetish  odor  of  the  breath,  the  glycosuria,  and 
the  subnormal  temperature. 

Trance. — In  this  condition  the  patient  lies  for  several 
days  apparently  dead,  the  pulse  and  respiration  being  im- 
perceptible.    It  is  usually  a  manifestation  of  hysteria. 

Somnambulism. — This  is  a  dream-like  state  in  which 
the  patient  performs  automatically  various  feats,  such  as 
walking,  singing,  writing,  etc.  Mild  forms,  such  as  talking 
and  walking  in  sleep,  may  occur  in  health.  More  marked 
manifestations  occur  in  hysteria  and  in  hypnotism. 

l^CStasy. — This  is  a  condition  of  apparent  insensibility  in 
which  the  mind  is  wholly  absorbed  with  a  fancy  or  delusion. 
It  occurs  in  the  hysteric.  The  dancing  mania  of  the  middle 
ages  is  a  good  illustration  of  it. 

Catalepsy. — This  is  a  state  of  motor  inertia,  the  limbs 
tending  to  remain  for  long  periods  in  any  position  in  which 
they  are  placed.  During  the  attacks  the  patient  is  appar- 
ently insensible  to  external  impressions.  It  occurs  in 
hysteria,  hypnosis,  certain  psychoses  (melancholia  attonita), 
and  rarely  in  organic  brain  disease. 


DISTURBANCES   OF   THE   SPECIAL   SENSES.  2)77 

DISTURBANCES  OF  THE  SPECIAL  SENSES* 

The  !]^ye. — Myosis.  —  Contraction  of  the  pupil  occurs 
in  many  conditions,  notably  in  locomotor  ataxia,  paretic 
dementia,  some  cases  of  disseminated  sclerosis,  meningitis, 
cerebral  tumor,  old  age,  uremia,  and  opium-poisoning. 

Mydriasis. — Dilatation  of  the  pupil  is  also  observed  in 
many  conditions,  notably  in  atrophy  of  the  optic  nerve, 
paralysis  of  the  third  nerve,  collapse,  severe  pain,  epileptic 
seizures,  hysteric  attacks,  belladonna-poisoning,  and  in  some 
cases  of  locomotor  ataxia  and  paretic  dementia. 

Inequality  of  the  Pupils. — This  may  occur  in  health,  in 
ocular  defects,  in  organic  brain  disease,  in  paretic  dementia, 
in  locomotor  ataxia,  in  aneurysm  pressing  on  the  cervical 
sympathetic,  and  in  unilateral  paralysis  of  the  oculomotor 
nerve. 

Argyll-Robertson  Pupil. — This  is  one  that  fails  to  respond 
to  li^ht,  but  still  accommodates  for  distance.  It  is  noted 
especially  in  locomotor  ataxia  and  paretic  dementia. 

Conjugate  Deviation  of  the  Eyes. — This  term  is  applied  to 
the  forcible  deflection  of  the  eyes  to  one  side,  the  visual  axis 
still  remaining  parallel.  It  is  a  common  symptom  in  gross 
lesions,  such  as  hemorrhage  or  tumor,  of  the  motor  centers 
or  their  tracts  in  the  brain.  When  the  lesion  is  cerebral  and 
destructive  the  eyes  are  turned  away  from  the  palsied  side 
(toward  the  lesion)  and  when  the  lesion  is  cerebral  and  irri- 
tative the  eyes  are  turned  toward  the  convulsed  side  (away 
from  the  lesion).  In  pontine  lesions  the  deviations  are  ex- 
actly reversed. 

Nystagmus  [Tremor  of  the  Eyeball). — It  may  be  congeni- 
tal, associated  with  certain  ocular  troubles,  or  due  to  disease 
of  basal  ganglia.  It  is  especially  frequent  in  disseminated 
sclerosis  and  Friedreich's  ataxia. 

Optic  Neuritis  or  Papillitis. — An  inflammatory  affection  of 
the  intra-ocular  end  of  the  optic  nerve.  The  term  ''  choked 
disk  "  is  used  to  designate  the  condition  when  it  is  accom- 
panied with  marked  swelling.  Its  chief  causes  are :  Tumor 
of  the  brain,  cerebral  meningitis,  syphilis,  toxic  agents  (lead 
and  alcohol),  infectious  fevers,  anemia,  and  Bright's  disease. 


SyS  DISEASES   OF   THE   NERVOUS  SYSTEM. 

Atrophy  of  the  Optic  Nerve. — As  a  primary  affection  it  is 
most  commonly  observed  in  locomotor  ataxia  and  paretic 
dementia.  Secondary  atrophy  results  from  pressure  of 
tumors,  aneurysms,  etc.,  on  the  optic  chiasm.  Consecutive 
atrophy  is  a  sequel  of  optic  neuritis. 

The  i^ar. —  Timiitits  Aiirhnn  {Noises  in  the  Ear^. — This 
is  observed  in  cerebral  hyperemia  and  anemia,  in  diseases  of 
the  ear,  in  Meniere's  disease,  and  after  the  use  of  certain 
drugs,  like  quinin  and  salicylic  acid. 

Hyperacusis  of  Hearing. — This  is  sometimes  observed  in 
hysteria,  in  facial  paralysis,  and  in  cerebral  hyperemia. 

Deafness  generally  depends  upon  disease  of  the  ear  itself. 

PSYCHIC  DISTURBANCES* 

Delusion. — A  delusion  is  a  faulty  belief  concerning  a 
subject  capable  of  physical  demonstration,  out  of  which  the 
person  cannot  be  reasoned  by  adequate  methods  for  the  time 
being  (Wood). 

A  systematized  dehision  is  one  which  the  patient  endeavors 
to  defend  by  a  process  of  reasoning  more  or  less  logical. 
Systematized  delusions  are  especially  observed  in  mono- 
mania. 

An  unsystematized  delusion  is  one  which  the  patient  makes 
no  attempt  to  justify;  he  asserts  his  belief  without  reason. 
The  majority  of  delusions  are  unsystematized,  and  as  such 
are  observed  in  most  forms  of  insanity. 

A  fixed  delusion  is  one  which  the  patient  retains  for  a  con- 
siderable length  of  time ;  it  is  frequently  systematized. 
Fixed  delusions  are  observed  in  monomania,  paretic  de- 
mentia, hysteric  insanity,  and  sometimes  in  melancholia. 

An  expansive  delusioii  or  a  delusion  of  grandeur  is  one 
which  exalts  its  possessor.  The  patient  conceives  that  he 
is  some  noted  personage,  that  he  is  worth  millions  of  dollars, 
or  that  he  is  capable  of  performing  certain  marvelous  feats. 
Expansive  delusions  are  frequently  observed  in  paretic  de- 
mentia, mania,  and  hysteric  insanity. 

A  hypocho?idriacal  delusion  is  one  which  depresses  its 
possessor.     The  patient  believes  that  he  has  committed  the 


PSYCHIC  DISTURBANCES.  379 

unpardonable  sin,  that  he  is  being  persecuted,  or  that  he  is 
the  victim  of  some  dread  disease.  Hypochondriacal  delusions 
are  frequently  observed  in  melancholia,  alcoholic  insanity,  and 
in  some  cases  of  monomania  and  paretic  dementia. 

Illusion. — An  illusion  Is  a  perverted  perception.  Thus 
in  delirium  tremens  the  patient  may  transform  every  piece 
of  furniture  into  a  demon  or  reptile. 

Hallucination. — A  hallucination  is  a  false  perception, 
entirely  subjective,  and  not  based  upon  any  knowledge  de- 
rived from  without.  An  individual  who  hears  voices  and 
sees  objects  when  none  exist  is  the  subject  of  hallucinations. 

Imperative  Conception. — A  conception  that  the  per- 
son knows  to  be  false,  but  that,  nevertheless,  dominates  his 
thoughts  and  often  directs  his  actions.  When  he  fails  to 
recognize  the  falsity  of  his  conception.  It  becomes  a  delusion. 

A  morbid  impulse  Is  an  irresistible  desire  to  commit  an 
act  which  the  patient  knows  to  be  wrong.  It  is  usually  the 
result  of  an  imperative  conception. 

Kleptomania  is  a  morbid  desire  to  steal.  Pyromania  is  a 
morbid  desire  to  set  fire  to  buildings. 

Delirium. — Delirium  is  a  mental  state  characterized  by 
a  rapid  flight  of  ideas  that  are  incoherent  and  often  unintel- 
ligible.    It  may  result  from  : 

Acute  Delirimn  {Bell's  Mania).— A  disease  arising  without 
obvious  cause,  and  characterized  by  an  abrupt  onset,  active 
delirium,  a  constant  repetition  of  certain  phrases  or  acts, 
moderate  fever,  often  a  bullous  eruption,  and  exhaustion.  It 
generally  ends  fatally  in  the  course  of  a  few  weeks. 

Mania. — In  this  affection  the  onset  is  not  abrupt.  Symp- 
toms of  impaired  health  and  mental  depression,  covering  a 
period  of  several  weeks  or  months,  generally  precede  the 
outbreak  of  the  delirium. 

Hysteria. — The  history,  age,  sex,  temperament,  and  the 
intermittent  character  of  the  delirium  will  aid  in  'the  diag- 
nosis. 

One  of  the  Infections  Fevers. — Pneumonia  and  typhoid 
fever  are  especially  liable  to  be  associated  with  delirium. 
The  physical  signs  in  the  former  and  the  abdominal  symp- 
toms in  the  latter  will  usually  indicate  the  diagnosis. 


380  DISEASES   OF   THE   NERVOUS  SYSTEM. 

Uremia. — The  urinous  odor  of  the  breath,  the  high  arterial 
tension,  the  accentuation  of  the  second  aortic  sound,  and  the 
presence  of  albumin  and  casts  in  the  urine  will  suggest 
uremia. 

Alcoholism. — The  history,  the  appearance  of  the  patient, 
the  marked  tremors,  and  frequently  terrifying  hallucinations 
will  indicate  alcoholism. 

Inanition. — A  form  of  delirium  occasionally  arises  in  the 
course  of  exhausting  diseases.  It  is  associated  with  pallor, 
feeble  pulse,  and  cold  extremities.  It  is  generally  of  short 
duration,  and  may  be  recognized  by  the  circumstances  under 
which  it  develops. 


DISEASES   OF  THE   BRAIN,  CORD,   NERVES, 

AND  MUSCLES.  ' 

ACUTE  CEREBRAL  LEPTOMENINGITIS. 

Definition. — An  acute  inflammation  of  the  pia  mater 
and  arachnoid. 

!^tiology.— (i)  It  may  be  a  primary  affection  excited  by 
the  Diplococcus  intracellularis  (sporadic  cerebrospinal  fever) 
or  by  the  pneumococcus,  (2)  It  may  be  tuberculous,  tuber- 
cle bacilli  from  a  primary  focus  of  disease  elsewhere  in  the 
body   reaching   the    meninges    through   the   blood-vessels. 

(3)  It  may  follow  injury,  disease  of  the  cranial  bones,  or 
otitis  media  (streptococcus,  staphylococcus,  pneumococcus). 

(4)  It  may  be  a  sequel  of  a  specific  fever — pneumonia, 
typhoid  fever,  diphtheria,  influenza  (pneumococcus.  Bacillus 
typhosus.  Bacillus  diphtheriae.  Bacillus  influenzae). 

Pathology. — The  membranes  are  usually  injected, 
cloudy,  and  more  or  less  edematous.  The  subarachnoid 
space  is  distended  with  a  seropurulent  or  purulent  exudate. 
The  substance  of  the  brain  may  also  be  involved.  The  ven- 
tricles are  often  somewhat  dilated  and  filled  with  cloudy 
lymph.  In  some  the  process  extends  over  the  entire  and 
even  to  the  spinal  cord ;  in  others  it  is  more  or  less  local- 
ized to  the  convexity  or  base.     The  tuberculous  form  and 


ACUTE    CEREBRAL   LEPTOMENINGiriS.  38 1 

that  following-  middle-ear  disease  are  usually  basilar.  In 
the  tuberculous  form,  which  is  nearly  always  secondary,  an 
infiltration  of  yellowish,  gelatinous  material  is  found  at  the 
base,  especially  about  the  optic  chiasm.  Small  tubercles 
can  usually  be  detected  along  the  blood-vessels  in  the 
Sylvian  fissures.  The  amount  of  fluid  in  the  lateral  ventri- 
cles is  often  considerably  increased  (acute  hydrocephalus). 

Symptoms. — The  onset  may  be  sudden  or  insidious. 
Headache,  severe  and  persistent,  is  rarely  absent.  Vomit- 
ing is  often  a  prominent  symptom,  especially  in  basilar 
meningitis.  It  frequently  occurs  independently  of  the 
presence  of  food  in  the  stomach.  The  temperature  is  mod- 
erately high  (i02°-i04°  F.)  and  very  irregular.  The  pulse 
is  generally  slow  (70  to  40  a  minute).  There  are  obstinate 
constipation  and  retraction  of  the  abdomen.  Irritation  of 
the  brain  is  soon  manifested  by  delirium,  contraction  of  the 
pupils,  photophobia,  intolerance  to  sound,  general  hyper- 
esthesia, muscular  twitchings,  and,  perhaps,  convulsions. 

When  the  exudate  is  sufficient  in  amount  to  exert  marked 
pressure,  paralytic  phenomena  develop.  Palsies,  gross  or 
localized,  take  the  place  of  convulsions  ;  coma  follows  de- 
lirium ;  the  pupils  dilate  and  the  eyes  roll  up;  photophobia 
is  replaced  by  blindness,  and  intolerance  to  sound  by  deaf- 
ness. If  the  finger  be  drawn  across  the  body,  a  bright-red 
line  develops  and  lingers  for  some  minutes  ;  this  is  the  tdclie 
cerebrale  of  Trousseau.  The  pulse  now  becomes  rapid  and 
irregular ;  the  respiration  assumes  the  Cheyne-Stokes  type, 
and  the  temperature  falls. 

When  the  process  involves  the  base,  retraction  of  the 
head  with  rigidity  of  the  back  of  the  neck,  optic  neuritis, 
and  paralysis  of  the  cranial  nei*\'es  are  prominent  symptoms. 
The  presence  of  pus,  leukocytes,  and  bacteria  in  fluid  ob- 
tained by  lumbar  puncture  is  an  important  sign  of  menin- 
gitis.^ 

Diagnosis. — In  tuberculous  meningitis  the  onset  is  usually 
insidious,  symptoms  of  ill  health  preceding  the  outbreak  for 
days  or  weeks ;  the  symptoms  of  a  basilar  involvement  are 
marked ;  tuberculous  lesions  may  be  detected  elsewhere  in 
the  body ;  tubercles  are  occasionally  seen  on  the  choroid. 


382  DISEASES   OF   THE   NERVOUS  SYSTEM 

and  finally  tubercle  bacilli  may  be  detected  in  the  fluid  ob- 
tained by  lumbar  puncture. 

Cerebrospinal  Fever. — In  this  disease  spinal  symptoms — 
opisthotonos,  pain  in  the  back,  and  contractures — are  usually 
marked  ;  there  may  be  a  purpuric  rash  ;  and  the  fluid  ob- 
tained by  lumbar  puncture  may  contain  the  Diplococcus 
intracellularis. 

Typhoid  Fever. — This  may  be  recognized  by  the  regular 
fever,  roseolar  rash,  abdominal  symptoms,  and  the  Widal 
reaction.  The  severe  cerebral  symptoms — delirium,  spasms, 
and  retraction  of  the  head — now  and  then  observed  in 
typhoid  fever  are  usually  due  to  cerebral  congestion  or  to 
the  toxemia,  and  only  very  rarely  to  meningitis. 

Prognosis. — Very  grave.  Recovery  never  occurs  in 
the  tuberculous  form,  and  only  in  very  rare  instances  in  the 
purulent  form.  The  duration  is  from  a  few  days  to  two  or 
three  weeks.  When  recovery  does  occur,  blindness,  paraly- 
sis, or  mental  impairment  is  apt  to  remain  as  a  permanent 
sequel. 

Treatment. — This  should  be  conducted  on  the  same 
lines  as  that  of  cerebrospinal  fever.  The  patient  should  be 
placed  in  a  quiet,  well-ventilated  room.  An  ice-bag  should 
be  applied  to  the  head.  In  the  robust,  wet  cups  or  leeches 
may  be  applied  to  the  neck.  Blisters  are  objectionable. 
The  diet  must  be  liquid.  Constipation  should  be  relieved 
by  enemas.  Restlessness,  headache,  and  convulsions  will 
call  for  bromids,  chloral,  phenacetin,  or  morphin.  Koplik 
has  reported  4  recoveries  in  5  cases  of  meningitis  due  to 
the  meningococcus,  in  which  lumbar  puncture  was  repeated 
at  frequent  intervals.  When  middle-ear  disease  is  the  ex- 
citing factor  and  the  symptoms  can  be  definitely  locaHzed, 
operation  may  be  justifiable. 

CHRONIC  CEREBRAL  LEPTOMENINGITIS. 

Definition. — A  chronic  inflammation  of  the  pia  mater. 

!^tiology. — It  may  result  from  syphilis,  alcoholism,  trau- 
matism, or  sunstroke.  It  may  be  secondary  to  acute  infec- 
tious leptomeningitis.  It  is  an  associated  condition  in  abscess 
and  tumors  of  the  brain. 


CHRONIC  PACHYMENINGITIS.  383 

Symptoms. — Persistent,  dull  headache,  mental  deterio- 
ration, vertigo,  muscular  weakness,  a  low  grade  of  optic 
neuritis,  and  occasionally  nausea,  vomiting,  and  tinnitus. 
Acute  exacerbations  are  not  infrequent,  and  are  character- 
ized by  fever,  severe  headache,  dehrium,  convulsions,  and 
stupor. 

Diagnosis. — Cerebral  Tumor. — In  tumor  the  symptoms 
are  more  severe  and  of  a  more  focal  character,  and  the  optic 
neuritis  is  of  a  high  grade. 

Uremia. — This  condition  may  be  recognized  by  the  albu- 
minuric retinitis  and  the  presence  of  albumin  and  casts  in 
the  urine. 

Prognosis. — More  or  less  unfavorable.  A  complete 
cure  is  sometimes  obtained  in  syphilitic  cases  when  specific 
treatment  is  instituted  early. 

Treatment. — In  syphilitic  meningitis  mercury  and  po- 
tassium iodid  should  be  used  freely.  In  other  instances 
courses  of  ergot  and  potassium  bromid  are  occasionally 
useful.  Applications  of  the  thermocautery  often  give  relief 
Tonics  and  hypnotics  are. frequently  indicated. 

CHRONIC  CEREBRAL  PACHYMENINGITIS* 

Definition. — Inflammation  of  the  dura  mater. 

[Etiology. — Inflammation  of  the  external  layer  may  re- 
sult fromx  injury,  syphiHs,  or  caries  of  the  bone.  Inflam- 
mation of  the  internal  layer  (hemorrhagic  pachymeningitis) 
is  most  commonly  met  with  in  chronic  insanities.  Less  fre- 
quently it  follows  trauma  of  the  head  or  sunstroke,  or  oc- 
curs in  chronic  alcoholism,  severe  anemia,  or  chronic  dis- 
ease of  the  blood-vessels. 

HEMORRHAGIC  PACHYMENINGITIS. 
(Hematoma  of  the  Dura  Mater.) 

This  condition  is  characterized  by  the  formation  of  layers 
of  new  delicate  connective  tissue  extraordinarily  rich  in  thin- 
walled  blood-vessels  from  which  the  blood  is  prone  to  es- 
cape, producing  hematomata  of  various  sizes. 

Symptoms. — Often  obscure.     In  some  cases  there  are 


384  DISEASES   OF   THE   NERVOUS  SYSTEM. 

no  manifestations  during  life.  •  When  the  condition  is  marked, 
the  following  phenomena  may  be  observed  :  Headache,  fail- 
ure of  memory,  impairment  of  intellect,  stupor,  contracted 
pupils,  local  convulsions,  or  palsies.  The  symptoms  may 
alternately  improve  and  grow  worse  for  a  long  period.  In 
grave  cases,  associated  with  extensive  hemorrhagic  effusion, 
the  symptoms  resemble  apoplexy. 

Diagnosis. — This  can  rarely  be  made  with  certainty. 

Prognosis. — Unfavorable. 

Treatment. — Grave  cases  should  be  treated  as  apoplexy. 

CHRONIC  HYDROCEPHALUS, 

(Congenital  Internal  Hydrocephalus ;  Water  on  the  Brain.) 

Definition. — A  condition  in  which  there  is  an  excessive 
accumulation  of  fluid  in  the  ventricles  of  the  brain. 

etiology. — The  disease  is  either  congenital  or  develops 
in  the  first  few  months  of  extra-uterine  life.  The  etiology  is 
obscure.  In  some  cases  the  effusion  appears  to  be  the  re- 
sult of  an  inflammatory  condition  of  the  ventricular  epen- 
dyma,  while  in  others  an  occlusion  of  the  communicating 
passages  between  the  ventricles  or  between  the  ventricles 
and  subarachnoid  space  seems  to  be  the  chief  cause. 

Pathology. — The  head  is  large  and  round ;  the  bones 
are  thin  and  translucent;  the  sutures  and  fontanels  are  en- 
larged, and,  if  life  has  been  prolonged,  are  filled  with 
numerous  Wormian  bones.  The  convolutions  of  the  brain 
are  flattened  and  the  sulci  more  or  less  obliterated.  The 
ventricles  are  greatly  distended  with  a  watery  fluid  of  low 
specific  gravity,  containing  a  trace  of  albumin.  The  epen- 
dyma  is  often  thickened  and  roughened.  Malformations  are 
frequently  observed,  and  probably  result  from  the  causes 
which  induced  the  effusion. 

Symptoms. — Sometimes  the  disease  develops  before 
birth,  and  the  large  head  interferes  with  the  delivery  of  the 
child.  In  other  cases  nothing  peculiar  is  observed  until  the 
child  is  several  months  old,  when  the  swelling  of  the  head 
attracts  the  attention  of  the  parents.  The  head  assumes  a 
globular  shape  ;  the  fontanels  and  sutures  remain  open  ;  the 


PARETIC  DEMENTIA.  385 

face  becomes  relatively  small ;  the  eyes  protrude  and  are 
directed  downward  from  the  pressure  of  the  fluid  on  the 
supra-orbital  plates  ;  the  scalp  appears  thin  and  stretched ; 
the  superficial  veins  are  distended ;  and  the  hair  becomes 
scant.  In  some  cases  the  head  is  so  heavy  that  the  thin 
neck  can  no  longer  support  it,  and  it  falls  forward  on  the 
breast. 

As  a  rule,  the  intelligence  is  considerably  impaired,  but 
exceptional  cases  are  marked  by  precociousness.  Motor 
phenomena  are  frequently  present ;  the  reflexes  are  exag- 
gerated ;  one  or  more  of  the  members  may  be  the  seat  of  a 
spastic  paralysis  ;  and  convulsions  develop  in  many  cases. 

The  duration  varies  in  different  cases.  The  large  majority 
soon  die  of  inanition,  convulsions,  or  some  intercurrent  dis- 
ease to  which  their  reduced  vitality  makes  them  an  easy 
prey  ;  but  in  a  few  cases  life  is  prolonged  for  many  years. 

Diagnosis. — Hydrocephalus  must  not  be  mistaken  for 
rachitic  enlargement  of  the  head.  In  the  latter  the  head  is 
square  instead  of  globular ;  the  intelligence  is  good ;  there 
are  no  motor  phenomena  ;  and  bony  enlargements  are  usually 
detected  at  the  ends  of  the  long  bones  and  at  the  junction 
of  the  cartilages  with  the  ribs. 

Prognosis. — Unfavorable.  In  a  few  cases  arrest  of  the 
disease  has  been  spontaneous  or  has  resulted  from  aspiration 
of  the  fluid. 

Treatment. — The  treatment  is  unsatisfactory.  In  the 
majority  of  cases,  beyond  dietetic  and  hygienic  measures  and 
the  occasional  use  of  tonics,  Httle  can  be  recommended. 
Tapping  of  the  ventricles  or  of  the  subarachnoid  space  in  the 
lumbar  region  (Quincke's  puncture),  with  gradual  compres- 
sion of  the  head  by  means  of  broad  strips  of  adhesive  plaster, 
sometimes  affords  temporary  relief 

PARETIC  DEMENTIA. 

(General  Paralysis  of  the  Insane;   General  Paresis;   Chronic 
Meningo-encephalitis.) 

Definition. — A  chronic    inflammatory  affection   of   the 
cerebral   cortex,  characterized  by  a  change  of  disposition, 
25 


386  DISEASES   OF   THE   NERVOUS  SYSTEM. 

failure  of  memory,  mental  exaltation,  delusions  of  grandeur, 
tremors,  epileptiform  seizures,  and  paralysis. 

;^tiolog"y. — It  occurs  most  frequently  between  the  ages 
of  thirty  and  fifty.  It  is  much  more  common  in  men  than 
in  women.  The  exciting  causes  are :  Prolonged  mental 
strain,  nervous  shock,  syphilis,  alcohohsm,  sunstroke,  and 
traumatism.     Of  these,  syphilis  is  by  far  the  most  potent. 

Pathology. — The  membranes  are  opaque,  thickened,  and 
at  places  adherent  to  the  brain  substance.  The  cortex  is 
more  or  less  atrophied  and  increased  in  firmness.  Micro- 
scopic examination  reveals  a  marked  increase  in  the  neu- 
ralgia, with  numerous  spider  cells,  thickening  of  the  vessel- 
walls,  distention  of  the  perivascular  spaces  with  round  cells, 
and  degeneration  of  the  ganglion-cells  and  atrophy  of  the 
nerve-fibers. 

In  some  cases  similar  degenerative  changes  are  observed 
in  the  posterior  and  lateral  columns  of  the  cord. 

Symptoms. — The  disease  usually  begins  insidiously 
with  a  change  in  disposition  :  the  industrious  become  sloth- 
ful ;  the  ambitious,  apathetic ;  the  chaste,  dissolute ;  the 
liberal,  parsimonious ;  the  complaisant,  churlish ;  and  the 
truthful,  false.  The  energy  relaxes,  the  judgm.ent  weakens, 
and  the  memory  fails.  As  the  faculties  become  impaired, 
a  peculiar  egotism  and  a  mental  exaltation  develop ;  the 
patient  becomes  boastful,  loquacious,  and  easily  provoked 
to  furious  outbreaks.  The  failure  of  memory  is  early  noted 
in  writing,  by  the  use  of  wrong  letters  and  the  suppression 
of  syllables.  At  this  time  motor  phenomena  may  be 
observed  :  the  tongue  trembles  when  it  is  protruded ;  the 
speech  is  slow,  hesitating,  and  indistinct ;  the  pupils  are 
often  unequal ;  and  the  gait  is  somewhat  shuffling. 

The  most  characteristic  psychic  symptom  of  fully  de- 
veloped paretic  dementia  is  the  delusion  of  grandeur:  the 
patient  conceives  that  he  is  some  distinguished  personage, 
that  he  owns  acres  of  land,  or  that  he  is  the  inventor  of 
Some  wonderful  machine.  The  mind  is  usually  serene  and 
cheerful,  but  periods  of  profound  depression  are  not  infre- 
quent. The  sensibilities  are  blunted,  and  the  animal  nature 
emphasized.     The  mind  becomes  more  and  more  involved ; 


CEREBRAL   PARALYSIS  IN  CHILDREN.  387 

there  is  extreme  indifference  to  all  that  transpires ;  the 
appetite  is  voracious,  and  in  eating  the  patient  bolts  his  food 
and  soils  his  clothes.  The  tremor  of  the  tongue  increases, 
and  spreads  to  the  lips  and  other  parts  of  the  face  ;  the  speech 
is  indistinct  and  "  scanning  "  ;  the  pupils  fail  to  respond  to 
light,  but  still  accommodate  for  distance  (Argyll-Robertson 
pupil) ;  and  the  reflexes  are  generally  increased,  though  they 
may  be  lost.  Seizures  of  an  epileptiform  or  apoplectiform 
character  are  not  uncommon. 

In  the  final  stage  mental  power  is  almost  obliterated ;  the 
health  fails ;  the  bladder  and  rectum  become  unretentive ; 
the  gait  is  more  unsteady ;  and  at  last  the  patient  is  unable 
to  leave  his  bed.  Death  usually  results  from  exhaustion 
or  intercurrent  disease. 

Diagnosis. — The  insidious  change  in  disposition,  failure 
of  memory,  indistinct  speech,  tremors,  Argyll-Robertson 
pupil,  and  delusions  of  grandeur  are  the  diagnostic  features. 

Cerebral  Syphilis. — In  this  disease  the  history,  the  occur- 
rence of  convulsions  and  of  partial  facial  palsies,  the  absence 
of  delusions  of  grandeur,  of  indistinct  speech,  of  tremors, 
and  the  effect  of  treatment  will  usually  prevent  an  error  in 
diagnosis. 

Prognosis. — Unfavorable.  The  course  is  not  uniform  : 
occasionally  there  are  remissions,  or  lucid  intervals,  which 
last  for  several  months  or  even  years.  The  average  dura- 
tion is  from  two  to  three  years. 

Treatment. — This  is  chiefly  hygienic  and  dietetic  The 
avoidance  of  mental  and  physical  excitement  is  imperative. 
When  there  is  a  suspicion  of  syphilis,  iodids  and  mercurials 
should  be  given  a  thorough  trial.  As  a  rule,  patients  must 
be  removed  to  asylums. 

CEREBRAL  PARALYSIS  IN  CHILDREN, 

(Spastic  Paralysis  of  Infants.) 

Definition. — Hemiplcg-ia,  diplegia,  or  paraplegia  ap- 
pearing at  birth  or  in  the  first  few  years  of  life,  and  usually 
associated  with  atrophy  and  sclerosis  of  the  cerebral  cortex, 
or  porencephalus. 


388  DISEASES   OF   THE   NERVOUS  SYSTEM. 

Patholog'y. — After  death  one  of  the  following  conditions 
is  found :  Porencephalus  (cystic  condition  of  the  brain), 
atrophy  and  sclerosis  of  the  convolutions,  meningo-encepha- 
litis,  or  meningeal  hemorrhage. 

Symptoms. — In  the  hemiplegic  variety  the  onset  is  sud- 
den, and  is  frequently  attended  with  fever,  convulsions,  or 
coma.  After  a  few  hours  or  days  these  severe  symptoms 
subside,  and  the  child  is  left  paralyzed  on  one  side  of  the 
body.  In  rare  instances  the  paralysis  ultimately  disappears 
and  the  child  is  restored  to  health,  but  in  the  large  majority 
of  cases  it  persists  and  is  followed  by  secondary  rigidity. 
Imbecility,  epilepsy,  and  choreiform  or  athetoid  movements 
in  the  affected  members  are  very  common  sequelae. 

The  diplcgic  or  paraplegic  form  [Little's  disease)  usually 
dates  from  birth,  and  is  characterized  by  rigidity  and  loss  of 
power  in  the  arms  and  legs,  or  in  the  legs  alone.  Chorei- 
form or  athetoid  movements  are  frequently  present.  Chil- 
dren thus  affected  are  generally  idiots  or  imbeciles.  Menin- 
geal hemorrhage,  induced  by  tedious  labor  or  the  use  of  the 
forceps,  appears  to  be  chiefly  responsible  for  this  variety. 

Treatment. — During  the  convulsive  stage  an  ice-bag 
should  be  applied  to  the  head,  and  chloral  or  bromid  admin- 
istered by  the  mouth  or  rectum.  The  paralysis  resists  treat- 
ment ;  but  subsequent  rigidity  may  be  lessened  by  massage 
and  passive  movements,  and  the  deformity  by  mechanical 
appliances.^ 


CEREBRAL  HYPEREMIA* 

(Congestion  of  the  Brain.) 

I^tiology. — Acute  congestion  results  from  exposure  to 
the  sun ;  from  the  use  of  certain  drugs,  like  alcohol  and 
nitroglycerin ;  from  excessive  brain-work ;  or  from  some 
reflex  disturbance,  as  gastric  irritation. 

Chronic  congestion  results  from  some  local  obstruction  to 
the  return  of  blood  from  the  brain,  as  by  a  tumor  in  the 
neck ;    from  obstruction  to  the  general   circulation,   as    in 

1  The  foregoing  description  is  based  upon  Osier's  elaborate  monograph. 


CEREBRAL   ANEMIA.  389 

chronic  heart  and  lung  disease  ;  from  the  suppression  of 
some  habitual  discharge,  as  the  menstrual  flow  at  the  meno- 
pause ;  or  from  some  general  cause,  such  as  prolonged 
anxiety,  overwork,  excesses,  irregular  living,  etc. 

Symptoms. — Acute  Form. — The  chief  symptoms  are  : 
Intense  headache ;  vertigo  ;  intolerance  to  light  and  sound  ; 
restlessness ;  tinnitus  aurium ;  and  sleeplessness,  or  sleep 
disturbed  by  horrible  dreams. 

Chronic  Form. — This  is  characterized  by  vertigo ;  dull 
headache ;  failure  of  memory ;  irritability ;  inability  to  con- 
centrate the  thoughts  ;  and  disturbed  sleep.  The  symptoms 
grow  worse  when  the  recumbent  posture  is  assumed.  Oph- 
thalmoscopic examination  reveals  retinal  hyperemia.  In 
marked  cases  there  may  be  exacerbations  closely  resembling 
a'poplexy,  in  which  there  is  unconsciousness,  followed  by 
temporary  paresis. 

Prognosis. — The  prognosis  depends  on  the  cause;  when 
this  can  be  removed,  the  prognosis  is  favorable. 
•  Treatm.ent.- — Acute  Congestion. — The  patient  should  be 
placed  in  a  darkened,  well-ventilated  room.  The  head  and 
shoulders  should  be  slightly  elevated.  An  ice-bag  should 
be  applied  to  the  head.  In  some  cases  leeches  or  wet-cups 
may  be  applied  to  the  neck.  Sedatives  like  bromid  of  potas- 
sium and  aconite  sometimes  do  much  good.  Hot  foot-baths 
are  often  serviceable.  If  there  is  constipation,  it  should  be 
relieved  by  a  brisk  saline  purge. 

In  chro7iic  cases  the  cause  should  be  ascertained,  and,  if 
possible,  removed.  The  habits  of  the  patient  must  be  regu- 
lated. The  diet  must  be  light  and  nutritious.  Constipation 
must  be  relieved  by  diet  or  by  the  occasional  use  of  a  saline 
laxative.  Sedatives  like  bromid  of  potassium  and  aconite 
are  useful.  In  the  apoplectiform  attacks  venesection  is  indi- 
cated. 

CEREBRAL  ANEMIA. 

!^tiolog"y. — General  cerebral  anemia  as  a  chronic  affection 
may  result  from  cardiac  disease,  especially  aortic  stenosis. 
It  may  be  associated  with  general  anemia.  It  may  be  due 
to  atheromatous  obstruction  of  the  arteries. 


390  DISEASES   OF   THE   NERVOUS  SYSTEM. 

Overwork,  prolonged  emotional  excitement,  irregular  liv- 
ing, and  excesses  are  also  said  to  predispose. 

As  an  acute  condition  it  exists  in  syncope  and  shock ;  after 
hemorrhage;  after  the  sudden  withdrawal  of  fluid  from  the 
abdominal  cavity ;  and  after  ligation  of  the  carotid  artery. 

Symptoms. — Acute  Form. — Pallor  of  the  face,  vertigo, 
confusion  of  ideas,  ringing  in  the  ears,  dimness  of  vision, 
dilatation  of  the  pupil,  nausea,  and  a  tendency  to  yawn.  In 
extreme  anemia  there  may  be  convulsions  and  coma. 

The  cJironic  form  is  characterized  by  vertigo,  headache, 
disturbed  sleep,  intolerance  to  light  and  sound,  irritability 
of  temper,  failure  of  memory,  inability  to  concentrate  the 
attention  on  one  subject,  a  tendency  to  syncope,  and  ex- 
treme lassitude.  The  symptoms  improve  when  the  patient 
lies  down. 

Diagnosis. — Cerebral  anemia  closely  simulates  cerebral 
congestion,  but  in  the  latter  there  is  no  tendency  to  syncope ; 
the  symptoms  grow  worse  when  the  patient  lies  down  ;  the 
pupils  are  contracted  instead  of  dilated,  and  the  urine  is  apt 
to  be  decreased. 

Prognosis. — The  prognosis  depends  on  the  cause ;  when 
this  can  be  removed,  the  prognosis  is  favorable. 

Treatment. — In  acute  cases  diffusible  stimulants  like 
nitroglycerin,  ammonia,  and  alcohol  are  indicated.  In 
chronic  cases  the  cause  should  be  ascertained,  and,  if  pos- 
sible, removed.  When  it  is  due  to  general  anemia,  iron, 
arsenic,  and  quinin  are  useful  remedies.  When  dependent 
on  valvular  disease,  rest  and  the  use  of  digitalis,  strophanthus, 
or  strychnin  are  the  remedial  measures. 

CEREBRAL  HEMORRHAGE. 

(Cerebral  Apoplexy.) 

!]^tiolog"y. — The  affection  is  most  commonly  met  with  in 
persons  over  forty,  in  whom  the  blood-vessels  are  athero- 
matous, but  it  may  occur  in  childhood  or  infancy.  All  causes 
that  lead  to  degeneration  of  the  arteries,  such  as  rheumat- 
ism, gout,  syphilis,  alcoholism,  and  Bright's  disease,  pre- 
dispose to  it.     Sufferers  from  chronic  Bright's  disease  are 


CEREBRAL   HEMORRHAGE.  39 1 

very  liable  to  die  of  apoplexy  on  account  of  the  association 
of  cardiac  hypertrophy  with  arterial  degeneration.  Heredity 
predisposes,  inasmuch  as  members  of  certain  families  are 
particularly  prone  to  sclerosis  of  the  vessels.  The  attack 
may  be  precipitated  by  mental  or  physical  excitement,  alco- 
hoHc  excess,  or  some  reflex  disturbance,  as  gastric  irritation. 

In  children  it  may  be  excited  by  a  paroxysm  of  whoop- 
ing-cough or  by  a  convulsion.  Occasionally,  it  occurs  after 
diphtheria  or  scarlet  fever,  the  toxins  of  these  diseases  pro- 
ducing degenerative  changes  in  the  arterial  walls. 

Pattiology. — In  children  the  hemorrhage  is  most  com- 
monly cortical ;  in  adults  it  is  usually  within  the  brain-mass. 
The  blood-vessels  are  generally  atheromatous,  and  are  some- 
times the  seat  of  miliary  aneurysms.  The  hemorrhage  varies 
greatly  in  quantity :  sometimes  it  is  small — merely  a  capil- 
lary oozing ;  at  other  times  it  may  flood  an  entire  hemi- 
sphere. Its  most  common  seat  is  the  internal  capsule — the 
motor  highway  between  the  optic  thalamus  and  the  corpus 
striatum.  In  recent  hemorrhages  the  clot  is  dark  and  soft, 
and  the  surrounding  tissue  stained  and  more  or  less  lacer- 
ated. If  the  hemorrhage  has  not  been  very  copious,  the 
clot  loses  its  color,  shrinks,  and  is  finally  absorbed,  and  the 
damaged  cerebral  fibers  are  replaced  by  proliferated  con- 
nective tissue,  which  contracts  and  forms  a  scar  more  or  less 
pigmented  with  hematoidin.  In  other  cases,  instead  of  a 
scar,  a  cyst  is  formed  that  incloses  a  clear,  straw-colored 
fluid. 

Large  effusions  are  followed  by  secondary  changes,  which 
are  systemic  and  extend  in  the  direction  in  which  the 
affected  nerve-fibers  transmit  impulses  ;  that  is,  toward  the 
periphery,  if  the  fibers  are  motor,  and  toward  the  nerve- 
centers  if  they  are  sensory.  After  an  extensive  lesion  of  the 
internal  capsule  secondary  degeneration  of  the  motor  tracts 
soon  begins  and  may  be  traced  downward  into  the  spinal 
cord. 

Symptoms. — Prodronial  syniptoins  indicating  cerebral 
congestion  frequently  precede  the  attack ;  these  are  head- 
ache, vertigo,  disturbed  sleep,  tinnitus  aurium,  and,  perhaps, 
a  sense  of  numbness  or  weakness  on  the  side  that  is  to  be 


392  DISEASES   OF   THE   NERVOUS  SYSTEM. 

affected.     Persistent  vomiting  sometimes  precedes  the  hem- 
orrhage. 

The  Attack. — In  many  cases  the  patient  falls  suddenly  un- 
conscious without  previous  warning.  The  face  is  flushed; 
the  eyes  are  injected ;  the  lips  are  blue ;  the  breathing  is 
stertorous;  the  pulse  is  full  and  slow;  the  temperature  is  at 
first  subnormal  from  shock,  but  later  it  is  elevated  from  irri- 
tation ;  and  the  urine  and  feces  may  be  passed  involuntarily. 
Convulsive  seizures  are  not  infrequent ;  they  result  from 
irritation  transmitted  to  the  undamaged  motor  regions. 
Even  while  the  patient  is  comatose,  the  paralysis  may  be 
detected.  The  head  and  eyes  may  be  strongly  rotated  to- 
ward the  side  of  the  hemorrhage  (conjugate  deviation)  ;  one 
cheek  often  flaps  more  than  the  other;  the  pupils  may  be 
unequal ;  any  movements  that  the  patient  may  make  are  re- 
stricted to  the  sound  side ;  when  the  affected  arm  is  raised 
and  let  fall,  it  drops  lifeless  ;  and  occasionally  the  tempera- 
ture is  higher  in  the  axilla  of  the  paralyzed  side.  In  grave 
cases  the  patient  does  not  awake  from  the  coma ;  the  pulse 
grows  feeble ;  the  respirations  assume  the  Cheyne-Stokes 
type ;  the  reflexes  are  abolished ;  mucus  collects  in  the 
throat  and  produces  a  rattling  sound  ;  the  temperature  rises 
to  103°  to  104°  ;  and  death  results  after  the  lapse  of  a  few 
hours  or  one  or  two  days. 

In  certain  cases  the  paralysis  rapidly  sets  in,  but  uncon- 
sciousness develops  gradually  and  does  not  become  com- 
plete for  twenty-four  hours  (ingravescent  apoplexy).  In 
other  cases  of  cerebral  hemorrhage  loss  of  consciousness  is 
very  transient  or  wholly  wanting. 

Sitbseqticnt  Symptoms. — When  the  attack  does  not  prove 
fatal,  consciousness  is  usually  restored  in  from  twelve  to 
forty-eight  hours,  and  if  the  hemorrhage  is  in  its  usual  lo- 
cation, there  remains  a  hemiplegia  on  the  opposite  side. 
The  muscles  of  the  upper  part  of  the  face  and  thorax,  how- 
ever, usually  escape,  because  they  are  accustomed  to  act 
in  unison  with  their  fellow  on  the  opposite  side,  and  such 
muscles  appear  to  be  innervated  from  both  sides  of  the  brain. 
When  the  tongue  is  protruded,  it  deviates  toward  the  para- 
lyzed  side.      The   deep   reflexes   are   exaggerated   on  the 


CEREBRAL   HEMORRHAGE.  393 

affected  side  and  tickling  the  sole  of  the  foot  causes  exten- 
sion of  the  great  toe  (Babinski's  sign).  Aphasia  is  common 
with  right  hemiplegia.  There  is  no  tendency  to  rapid  wast- 
ing of  the  affected  muscles.  Sensation  is  unimpaired  unless 
the  posterior  limb  of  the  internal  capsule  is  also  involved, 
when  there  is  hemianesthesia  with  the  hemiplegia.  The  gait 
is  pecuHar ;  in  walking  the  patient  supports  the  paralyzed 
arm  and  swings  the  leg  forward  by  a  rotary  movement  im- 
parted to  it  by  the  trunk.  When  the  clot  has  been  small, 
the  paralysis  may  completely  disappear.  More  frequently, 
recovery  is  only  partial.  The  power  of  the  facial  muscles 
is  generally  restored  entirely,  and  the  leg  usually  improves 
more  than  the  arm. 

In  unfavorable  cases  the  muscles  become  rigid  from  a  de- 
generative process  traveling  down  the  direct  and  crossed 
pyramidal  tracts  of  the  spinal  cord ;  this  condition  is  indic- 
ative of  permanent  disability. 

Mental  symptoms,  especially  impairment  of  memory  and 
loss  of  emotional  control,  frequently  follow  the  attack. 

Diagnosis. — The  coma  of  apoplexy  must  be  distinguished 
from  uremia,  opium-poisoning,  alcoholism,  and  sunstroke.  The 
age  of  the  patient ;  the  condition  of  the  arteries  ;  the  evidence 
of  paralysis  ;  the  difference  of  temperature  in  the  two  axillae  ; 
and  the  absence  of  other  cause  will  usually  prevent  an  error 
in  diagnosis. 

Embolism. — This  usually  occurs  in  earlier  life ;  it  is 
commonly  associated  with  valvular  disease ;  premonitory 
symptoms  are  rarely  present ;  the  pulse  is  more  often  weak 
than  strong;  disturbances  of  temperature  and  breathing  are 
less  marked. 

Thrombosis. — This  also  produces  hemiplegia ;  but  its  de- 
velopment is  usually  gradual ;  unconsciousness  is  often 
absent,  and  temperature  and  breathing  are  not  much  dis- 
turbed. 

Hemiplegia  from  Other  Causes. —  Tumors  and  abscess  in  the 
brain  may  produce  hemiplegia,  but  the  latter  develops  grad- 
ually and  is  usually  associated  with  other  cerebral  phenomena, 
such  as  persistent  headache,  vertigo,  ocular  palsies,  choked 
disk,  etc. 


394  DISEASES   OF   THE   NERVOUS  SYSTEM. 

Hysteric  Hemiplegia. — In  hysteria  the  face  escapes ;  there 
is  frequently  anesthesia  on  the  affected  side ;  the  gait  is 
peculiar,  in  that  the  patient  pushes  the  paralyzed  limb  in- 
stead of  swinging  it.  These  features,  together  with  the  age, 
temperament,  sex,  and  mode  of  onset,  will  usually  suggest  A 
the  true  cause. 

Prognosis. — Always  doubtful.  Persistent  and  complete 
unconsciousness,  high  temperature,  loss  of  reflexes,  and  em- 
barrassed respiration  are  unfavorable  phenomena.  When 
the  attack  does  not  prove  fatal,  there  is  always  danger  of 
recurrence,  since  the  etiologic  conditions  still  remain. 

Treatment. — Prophylaxis. — Patients  predisposed  to  apo- 
plexy should  lead  a  quiet  life,  free  from  mental  and  physical 
excitement.  The  diet  should  be  nutritious,  but  easily  digest- 
ible. Constipation  should  be  relieved  by  the  occasional  use 
of  a  saline  laxative.  To  secure  a  free  return  of  the  blood 
from  the  brain  the  clothes  at  the  neck  should  be  loose. 

The  Attack. — The  head  and  shoulders  should  be  slightly 
elevated,  and  an  ice-bag  applied  to  the  head.  Croton  oil  (i 
to  3  drops)  in  a  Httle  glycerin  or  olive  oil  may  be  placed  on 
the  back  of  the  tongue  to  secure  prompt  catharsis.  If  the 
pulse  is  strong,  venesection  is  indicated  and  should  be  con- 
tinued until  the  pulse  softens.  Bleeding  cannot  undo  the 
damage  already  done,  but  by  relieving  cerebral  congestion, 
it  may  serve  to  arrest  bleeding  that  is  still  in  progress  or  to 
prevent  an  early  recurrence.  On  the  other  hand,  when  the 
face  is  pale  and  the  pulse  feeble,  stimulants,  like  ammonia, 
ether,  and  camphor,  should  be  given  very  cautiously.  When 
collections  of  mucus  interfere  with  breathing,  the  patient 
should  be  gently  turned  on  his  side  and  the  mucus  removed 

To  prevent  the  formation  of  bed-sores  the  position  should 
be  frequently  changed  and  the  parts  subjected  to  pressure 
thoroughly  cleansed. 

Subsequent  Treatment. — Even  in  the  mildest  cases  the  I 
patient  should  not  be  allowed  to  leave  his  bed  for  two  or 
three  weeks,  and  during  this  time  the  diet  should  be  light 
and  unstimulating.  After  the  acute  symptoms  have  entirely 
disappeared,  which  will  rarely  be  earlier  than  ten  days  or 
two  weeks  after  the  attack,  massage  should  be  systematically      | 


OBSTRUCTION  OF   THE    CEREBRAL   ARTERIES.     395 

practised.  It  aids  in  the  restoration  of  power  and  in  the 
prevention  of  contractures.  After  the  lapse  of  three  or  four 
weeks  triweekly  applications  of  the  faradic  current  may  be 
of  service.  Strychnin  is  often  given  at  this  time,  but  it 
probably  exerts  no  other  influence  than  that  of  a  general 
tonic.  In  some  cases  warm  saline  baths  (90°-95'^  F.)  com- 
bined with  passive  movements  prove  useful  adjuvants. 

OBSTRUCTION  OF  THE  CEREBRAL  ARTERIES^ 

(Embolism;  Thrombosis.) 

etiology. — Cerebral  emboli  may  be  derived  from  the 
valves  of  the  heart  in  endocarditis ;  from  an  atheromatous 
plate  in  the  aorta ;  or  from  thrombus  in  the  heart  or  in  the 
sac  of  an  aneurysm.  Obstruction  from  embolism  may  occur 
at  any  age,  but  it  is  far  more  commonly  observed  in  young 
adults  than  at  the  extremes  of  life. 

Cerebral  thrombi  are  usually  caused  by  atheroma  or  syphi- 
litic endarteritis.  They  are  usually  observed  In  advanced 
years,  but  those  dependent  on  syphilis  frequently  occur  in 
early  adult  or  middle  life. 

Pathology. — Emboli  are  most  frequently  found  in  a 
branch  of  the  left  middle  cerebral  artery.  When  the  artery 
obstructed  is  a  large  one,  infarction  of  the  brain  with  soften- 
ing ensues.  If  the  area  affected  is  small,  absorption  of  the 
dead  tissue  usually  follows,  with  the  formation  of  a  cicatrix. 
Infective  emboli  give  rise  to  abscesses. 

Thrombi  are  usually  found  in  the  basilar,  middle  cerebral, 
or  vertebral  arteries,  and  produce  the  same  lesions  as  emboli. 

Symptoms. — An  embolus  lodging  in  the  middle  cerebral 
artery  usually  causes  abrupt  hemiplegia  and  frequently 
aphasia.  There  may  be  no  prodromes,  and  consciousness 
may  be  preserved  during  the  seizure. 

When  the  basilar  artery  is  obstructed,  there  may  be  ex- 
tensive paralysis  on  both  sides  of  the  body,  and  later  symp- 
toms of  bulbar  disease — namely,  paralysis  of  the  lips,  pharynx, 
and  esophagus,  disturbance  of  the  heart,  and  Cheyne-Stokes 
breathing. 

In  thrombosis  the  symptoms  are  similar  to  embolism,  but 


396.  DISEASES   OF   THE   NERVOUS  SYSTEM. 

they  develop  more  slowly,  and  are  frequently  preceded  by 
prodromes  indicating  disturbed  cerebral  circulation,  such  as 
headache,  vertigo,  disturbed  sleep,  failure  of  memory,  numb- 
ness and  tingling  in  the  limbs  to  be  affected.  There  is  a 
marked  tendency  to  recurrence  of  attacks. 

Subsequent  Symptoms.- — In  both  embolism  and  thrombosis, 
if  the  artery  obstructed  has  been  large,  the  paralysis  is  likely 
to  persist  and  to  be  followed  by  symptoms  of  cerebral  soften- 
ing— namely,  failure  of  memory,  vertigo,  headache,  disturbed 
sleep,  irritability,  and  finally  dementia. 

Diagnosis. — The  differential  diagnosis  between  cerebral 
embolism  or  thrombosis  and  hemorrhage  has  already  been 
considered  (see  p.  393). 

Prognosis. — The  prognosis  is  always  grave  ;  unless  the 
symptoms  are  slight,  complete  recovery  is  rare. 

Treatment. — After  obstruction  from  embolism  the  pa- 
tient should  be  kept  at  absolute  rest  for  a  week  or  two,  and 
subsequently  the  paralysis  treated  as  after  apoplexy.  In 
thrombosis  treatment  is  rarely  of  avail ;  in  syphilitic  cases, 
however,  active  antiluetic  treatment  should  be  instituted. 

MORBID  GROWTHS  IN  THE   BRAIN. 

(Tumors  of  the  Brain.) 

etiology. — The  etiology  of  brain  tumors  is  obscure. 
Males  are  more  frequently  affected  than  females.  No  age 
is  exempt,  but  the  majority  of  brain  tumors  occur  between 
the  ages  of  thirty  and  fifty.  Occasionally  the  history  of 
some  remote  injury  is  obtainable.  Heredity  predisposes  to 
the  extent  that  it  favors  the  development  of  tubercle  and 
cancer. 

Varieties. — Tubercle,  gumma,  gUoma,  aneurysm,  cysts, 
sarcoma,  and  carcinoma  are  the  most  common  varieties. 
Less  frequently  fibroma,  psammoma,  and  lipoma  are  ob- 
served. 

Pathology. —  Tuberculous  tumors  or  tyromata  vary  in 
size  from  that  of  a  pea  to  that  of  an  ^^^ ;  they  may  be  sin- 
gle or  multiple,  and  are  usually  observed  in  the  young. 

Gumma. — This  appears  as  a  round,  yellow,  caseous  mass. 


MORBID    GROWTHS  IN   THE   BRAIN.  397 

and  is  nearly  always  on  the  surface  of  the  brain,  into  which 
it  grows  from  the  overlying  membranes.  It  is  usually  met 
with  between  the  ages  of  thirty  and  forty. 

Glioma. — This  tumor  is  found  almost  exclusively  in  the 
brain.  It  arises  from  the  neuroglia,  and  may  be  soft,  like 
brain-substance,  or  firm,  like  fibrous  tissue.  It  is  chiefly 
met  with  in  the  young. 

Aneurysm. — EncephaHc  aneurysm  may  be  single  or  mul- 
tiple. Miliary  aneurysms  of  small  vessels  frequently  excite 
apoplexy.  The  most  common  seats  of  large  aneurysms  are 
the  middle  cerebral,  basilar,  and  internal  carotid  arteries. 

Cysts. — These  are  usually  congenital  (porencephalus)  or 
result  from  hemorrhage,  but  sometimes  they  result  from 
the  Taenia  echinococcus  (hydatid  cyst)  or  Taenia  solium 
(Cysticercus  cellulosae). 

Sarcoma. — This  is  usually  a  circumscribed  tumor,  and 
commonly  grows  from  the  membranes.  It  is  generally  pri- 
mary. 

Carcinoma. — This  is  nearly  always  secondary  and  multiple. 

Syttiptoms. —  General  Symptoms.  —  (i)  Headache  is 
rarely  absent ;  it  is  sometimes  localized  and  associated  with 
tenderness  on  pressure.  (2)  Vomiting  is  a  common  symp- 
tom, especially  in  tumors  of  the  base  of  the  brain  ;  it  is  often 
unassociated  with  nausea,  and  does  not  relieve  the  attend- 
ing headache.  (3)  Optic  neuritis  or  optic  atrophy  is  present 
in  about  80  per  cent,  of  the  cases.  (4)  Vertigo  is  often  marked, 
especially  in  tumors  of  the  basal  ganglia  and  cerebellum. 
(5)  Convulsions,  local  (Jacksonian  epilepsy)  or  general,  occur 
in  about  50  per  cent,  of  all  cases.  (6)  Psychic  phenomena — 
failure  of  memory,  depression  of  spirits,  irritability  of  tem- 
per, and  emotional  states — are  not  infrequently  present. 
Insomnia,  changes  in  the  rate  and  rhythm  of  the  pulse, 
polyuria,  and  glycosuria  are  occasional  symptoms. 

Focal  Symptoms. — These  depend  entirely  upon  the  loca- 
tion of  the  tumor.  The  following  are  the  chief  localizing 
symptoms : 

Prefrontal  Region. — Mental  torpor,  irritability,  and  drow- 
siness   deepening   into   stupor   frequently  appear.      Motor 


398 


DISEASES   OF   THE   NERVOUS  SYSTEM. 


agraphia  and  aphasia  may  result  from  compression  of  the 
second  and  third  frontal  convolutions. 

Motor  Region  {the  Aseending  Frontal  Convolution). — 
When  the  tumor  irritates  the  centers,  local  convulsions  de- 
velop ;  when  it  exerts  enough  pressure  to  destroy  function, 
paralysis  results. 

Posterior  Portion  of  the  Third  Frontal  Convolution  (Left 
Side). — Motor  or  ataxic  aphasia  is  a  characteristic  symptom. 

Temporal  Lobe,  First  and  Second  Convolutions  (Left  Side). 
— Tumors  in  this  region  cause  word-deafness. 


Fig.  i8. — Functional  areas  of  the  cerebral  cortex,  left  hemisphere. 


Angidar  and  Sup7^amarginal  Gyri  (Left  Side). — Word- 
blindness  and  apraxia  usually  develop. 

Parietal  Lobe. — Tumors  in  this  region  frequently  occasion 
disturbances  of  cutaneous  and  muscular  sensibility,  espe- 
cially a  loss  of  power  to  recognize  the  shape  of  objects  by 
touch  (astereognosis). 

Occipital  Lobe. — Hemianopsia  is  common,  and  there  may 
be  psychic  blindness  if  the  growth  is  on  the  left  side.  Word- 
blindness  may  also  result  from  pressure  on  the  angular 
gyrus. 


MORBID    GROWTHS   IN   THE  BR  AW.  399 

Internal  Capsule. — Lesions  of  the  middle  third  cause 
hemiplegia  on  the  opposite  side ;  of  the  posterior  third, 
hemianesthesia  of  the  opposite  side. 

Corpus  Striatum. — Large  lesions  produce  hemiplegia  from 
pressure  on  the  internal  capsule. 

Optic  Thalamus. — Large  lesions  may  produce  hemianes- 
thesia from  pressure  upon  the  posterior  limb  of  the  internal 
capsule  and  sometimes  hemianopsia. 

Corpora  Quadrigemina. — There  may  be  incoordination, 
oculomotor  palsies,  nystagmus,  and  loss  of  the  pupil- 
reflex. 

Cms  Cerebri. — Tumors  in  this  locality  cause  paralysis  of 
the  third  nerve  on  the  side  of  the  lesion  and  hemiplegia  on 
the  other  side. 

Pons. — Pontile  growths  may  occasion  hemiplegia  and 
hemianesthesia  on  the  side  opposite  to  the  lesion,  and  paraly- 
sis of  the  cranial  nerves,  especially  of  the  facial,  on  the  side 
of  the  lesion. 

Corpus  Callosum. — Tumors  in  this  region  may  cause 
mental  symptoms, — stupor,  irritability,  hallucinations,  attacks 
of  excitement, — followed  by  motor  paralysis. 

Cerebellum  [Middle  Lobe). — The  characteristic  symptoms 
are  headache,  staggering  gait,  vertigo,  and  vomiting. 
Paralysis  may  result  from  pressure  on  the  pyramidal  tracts. 

Diagnosis. — The  Character  of  the  Growth. — This  can- 
not always  be  determined.  The  early  age,  the  rapid  prog- 
ress, and  the  family  history  may  suggest  tubercle.  The 
early  age,  slow  progress,  and  mild  pressure-symptoms  may 
suggest  glioma.  The  history,  age,  and  concomitant  symp- 
toms will  indicate  syphilis.  The  presence  of  a  primary 
growth  will  lead  to  the  diagnosis  of  cancer.  The  presence 
of  a  thrill,  bruit,  and  marked  tinnitus  and  the  absence  of 
optic  neuritis  would  suggest  aneurysm. 

Abscess. — Cerebral  tumor  must  be  distinguished  from 
abscess.  The  latter  usually  results  from  traumatism  or  is 
secondary  to  a  focus  of  suppuration  in  some  other  part  of 
the  body ;  its  progress  is  usually  more  rapid ;  optic  neuritis 
is  less  common  ;  and  there  is  often  febrile  disturbance,  with 
leukocytosis. 


400  DISEASES   OF  THE  NERVOUS  SYSTEM. 

Chronic  Meningitis. — In  this  affection  the  symptoms  indi- 
cate a  diffuse  lesion ;  disturbances  of  temper,  memory,  and 
sleep  are  more  marked ;  optic  neuritis  is  not  frequent. 

Prognosis. — Always  grave.  When  the  tumor  is  not 
gummatous  and  is  not  suitable  for  operative  interference, 
the  prognosis  is  absolutely  unfavorable.  The  duration  is 
from  a  few  months  to  several  years. 

Treatment. — As  there  is  always  a  possibility  that  the 
tumor  is  syphilitic,  mercury  and  iodids  should  be  tried  in 
every  case  the  nature  of  which  is  in  the  least  uncertain. 
Operative  interference  must  be  considered  when  the  tumor 
is  localized  and  situated  in  the  cerebral  cortex  or  cerebel- 
lum. Less  than  ten  per  cent,  of  brain  tumors  are  open  to 
operation.-  Growths  in  the  motor  region  offer  the  best 
chances  of  success. 

In  inoperable  nonsyphilitic  growths  treatment  is  pallia- 
tive. Cold  applications  to  the  head,  bromids,  antipyrin,  and 
morphin  are  required  to  relieve  pain. 

ABSCESS  OF  THE  BRAIN- 

(Suppurative  Encephalitis.) 

Btiology. — (i)  It  may  be  traumatic.  (2)  It  may  be  sec- 
ondary to  suppurative  inflammation  of  adjacent  parts,  as 
caries  of  the  temporal  bone  following  otitis  media.  (3)  It 
may  be  secondary  to  some  distant  focus  of  suppuration,  as 
in  pulmonary  abscess,  hepatic  abscess,  ulcerative  endocar- 
ditis.    (4)  It  may  follow  one  of  the  infectious  fevers. 

Pathology. — The  abscess  varies  in  size  from  a  pea  to 
one  large  enough  to  fill  an  entire  hemisphere.  The  surround- 
ing tissues  are  hyperemic,  edematous,  and  more  or  less  in- 
filtrated. In  the  acute  form  the  abscess  is  diffuse,  but  in 
long-standing  cases  the  pus  is  encapsulated  by  a  thick 
fibrous  sac.  The  temporosphenoid  lobe  and  the  cerebellum 
are  the  most  frequent  seats.  Abscesses  secondary  to  distant 
foci  of  suppuration  are  commonly  multiple. 

Symptoms. — Abscesses  following  injury  frequently  run 
an  acute  course,  and  are  characterized  by  high  fever,  rigors, 
headache,  dehrium,  convulsions,  vomiting,  and  coma. 


APHASIA.  401 

In  chronic  cases  the  general  symptoms  are  headache,  ten- 
derness of  the  head  to  percussion,  irritability,  mental 
impairment,  vertigo,  vomiting,  stupor,  pallor,  and  loss  of 
flesh  and  strength.  The  temperature  is  variable ;  it  may 
be  elevated  but  not  rarely  it  is  normal  or  subnormal. 
The  focal  phenomena  vary  with  the  location  of  the  abscess. 
Involvement  of  the  motor  area  may  be  attended  with  con- 
vulsions or  paralysis  in  one  limb  ;  of  the  temporosphenoid 
lobe,  with  deafness  and  perhaps  aphasia ;  of  the  occipital 
lobe,  with  hemianopia ;  of  the  cerebellum,  with  persistent 
vomiting  and  loss  of  coordination. 

Prognosis. — Grave.  When  the  focal  symptoms  indicate 
involvement  of  an  accessible  region  like  the  motor  area, 
temporosphenoid  lobe,  or  cerebellum,  operative  interference 
affords  considerable  hope  of  success. 

Treatment. — When  the  abscess  is  located  in  one  of  the 
regions  specified,  the  skull  should  be  trephined  and  the  pus 
evacuated.  In  other  cases  the  application  of  wet  cups  to  the 
neck,  of  ice-bags  to  the  head,  and  the  internal  use  of  opium, 
bromid  of  potassium,  or  of  chloral  may  temporarily  relieve 
the  distress. 

APHASIA. 

Definition. — A  failure  of  word-memory ;  an  inability  to 
utter  words,  to  write  them,  or  to  comprehend  them. 

Varieties. — Motor  and  sensory. 

Motor  Aphasia. — Ataxic  Aphasia. — Impairment  or  loss  of 
articulate  speech  from  an  inability  to  recall  the  efforts 
needed  to  pronounce  words  rather  than  from  muscular 
paralysis.  It  is  the  most  common  form  of  aphasia.  The 
lesion  is  in  the  posterior  part  of  the  third  left  frontal  convo- 
lution (Broca's  region). 

Motor  Agraphia. — In  this  condition  the  patient,  though 
able  to  read,  is  unable  to  write  voluntarily  or  from  dictation, 
or  to  copy.  The  lesion  is  in  the  posterior  part  of  the 
midfrontal  convolution  (?). 

Paraphasia. — Misplacement  of  words  and  syllables.     The 

26 


402  DISEASES   OF   THE   NERVOUS  SYSTEM. 

patient  talks  jargon,  though  he  understands  what  he  hears 
and  sees  and  can  articulate  clearly.  The  lesion  is  in  one  of 
the  association  tracts  between  the  speech  centers. 

Sensory  Aphasia. —  Word-blindness  (^Alexia). — Inability  to 
recognize  written  or  printed  words.  The  lesion  is  situated 
in  the  angular  and  supramarginal  convolutions  of  the  left 
side.  The  patient  being  unable  to  call  to  mind  the  appear- 
ance of  words,  may  also  lose  the  power  to  write  spontane- 
ously (sensory  agraphia).  Word-blindness  is  usually  asso- 
ciated with  hemianopsia,  as  a  lesion  of  the  angular  gyrus  is 
very  apt  to  involve  the  underlying  visual  tracts. 

Word-deafness. — Inability  to  recognize  spoken  words. 
The  lesion  is  in  the  middle  of  the  first  and  second  temporal 
convolutions  of  the  left  hemisphere.  Though  the  patient 
may  be  able  to  read,  he  is  often  unable  to  speak  correctly, 
since  he  cannot  recall  the  sound  of  the  words. 

Apraxia. — This  is  a  loss  not  only  of  word  memories  but 
of  all  memories  having  to  do  with  sight,  hearing,  and  touch. 
The  patient  is  unable  to  recognize  objects  when  he  sees, 
hears,  or  touches  them.  When  the  loss  of  concepts  is 
complete  there  is  also  the  inability  to  employ  objects  in  the 
proper  way.  Apraxia  is  usually  associated  with  aphasia. 
The  following  are  the  chief  varieties  : 

Psychic  Blindness. — This  is  a  condition  in  which  objects 
are  seen,  but  not  recognized.  It  results  from  a  lesion  of 
the  occipital  lobe  and  is  usually  associated  with  hemian- 
opsia. 

Psychic  Deafness. — This  is  a  condition  in  which  not  only 
words,  but  all  sounds,  though  heard,  awaken  no  intelligent 
conception.  The  bark  of  a  dog,  for  instance,  calls  to  mind 
no  visual  image  of  the  animal.  Psychic  deafness,  like  word 
deafness,  results  from  a  lesion  of  the  left  temporal  convo- 
lutions. 

Astereognosis. — A  loss  of  the  power  of  recognizing 
objects  by  touch.  It  is  a  symptom  of  disease  in  the  middle 
portion  of  the  posterior  central  convolution  and  adjacent 
part  of  the  inferior  parietal  lobule. 

Pathology. — The  lesions  that  produce  aphasia  are  mani- 


SPINAL   LEPTOMENINGITIS.  403 

fold ;  the  most  important  are  :  Tumor,  gumma,  abscess,  de- 
pressed fracture,  embolism,  thrombus,  or  softening  in  the 
localities  that  correspond  to  the  various  forms  of  aphasia. 
In  right-handed  subjects  the  lesion  is  on  the  left  side  of  the 
brain  ;  in  the  left-handed  it  may,  however,  be  on  the  right 
side.  Aphasia  is  not  always  due  to  organic  disease  ;  it  may 
be  noted  in  congestion  of  the  brain,  in  sudden  fright,  in  the 
convalescence  of  fevers,  in  migraine,  after  epileptic  seizures, 
and  in  hysteria. 

Diagnosis. — Aphasia  must  be  distinguished  from  aphonia. 
The  latter  condition  is  an  inability  to  utter  sounds,  a  power 
not  lost  in  aphasia  ;  moreover,  aphonia  is  generally  depend- 
ent upon  some  abnormality  of  the  larynx  or  of  the  nerves 
leading  thereto. 

Prognosis. — This  depends  entirely  on  the  cause.  After 
apoplexy  the  prognosis  should  be  guarded.  In  cerebral 
softening  it  is  absolutely  unfavorable.  When  aphasia  de- 
velops in  the  young,  the  outlook  is  much  more  hopeful. 

Treatment. — The  causal  condition  will  require  attention. 
The  patient  may  be  instructed  to  speak  and  to  interpret  after 
the  manner  employed  in  teaching  the  young. 

SPINAL  LEPTOMENINGITIS^ 

(Spinal  Meningitis.) 

Definition. — An  inflammation  of  the  spinal  pia  mater. 

!]^tiolog"y. — Acute  spinal  leptomeningitis  usually  occurs 
as  a  part  of  cerebrospinal  meningitis.  As  a  primary  disease, 
without  involvement  of  the  cranial  meninges,  it  is  rare.  It 
occasionally  follows  one  of  the  infectious  fevers,  traumatism, 
or  exposure.     In  some  instances  it  is  tuberculous. 

Pathology. — Aade  Form. — The  membranes  are  opaque, 
thickened,  congested,  and  adherent.  The  fluid  in  the  arach- 
noid space  is  increased.  In  very  acute  cases  there  is  more 
or  less  purulent  infiltration.  The  periphery  of  the  cord  is 
always  involved. 

Chronic  Form. — The  membranes  are  very  thick  and  fuse(^ 
into  one  homogeneous  fibrous  mass. 


404  DISEASES   OF   THE   NERVOUS  SYSTEM. 

Symptoms. — Acute  Form. — The  disease  may  begin  with 
a  chill,  followed  by  a  moderate  fever.  There  is  intense  pain 
in  the  back,  radiating  along  the  course  of  the  nerves.  The 
back  is  tender.  The  spinal  muscles  are  rigid  and  contracted — 
sometimes  so  much  so  as  to  induce  opisthotonos.  The  re- 
flexes are  increased.  When  the  exudate  is  sufficient  to  make 
considerable  pressure  on  the  cord,  paralytic  phenomena  de- 
velop, such  as  slight  anesthesia  and  paresis  of  the  limbs. 

There  are  no  cerebral  symptoms  unless  the  meninges  of 
the  brain  are  involved. 

Diagnosis. — Myelitis. — In  this  affection  the  pain  is  less 
severe  ;  there  is  less  tendency  to  spasm  ;  paralysis  and  anes- 
thesia are  more  marked ;  the  bladder  and  rectum  are  early 
involved;  and  the  formation  of  bed-sores  is  common. 

Tetanus. — The  presence  of  a  wound  ;  the  absence  of  fever  ; 
the  early  involvement  of  the  jaw ;  and  the  absence  of  marked 
tenderness  in  the  back  will  suggest  tetanus. 

Prognosis. — Extremely  grave.  Recovery  sometimes  fol- 
lows, but  rarely  without  partial  paralysis. 

Chronic  Leptomeningitis . — This  is  characterized  by  pain  in 
the  back  ;  stiffness  of  the  muscles  ;  hyperesthesia  and  par- 
esthesia of  the  limbs,  but  rarely  anesthesia ;  some  loss  of 
power ;  and  exaggerated  reflexes. 

Treatment. — This  is  the  same  as  that  of  cerebrospinal 
meningitis. 

CHRONIC  SPINAL  PACHYMENINGITIS- 

(Cervical  Hypertrophic  Pachymeningitis;  Internal  Pachy- 
meningitis.) 

Definition. — A  chronic  inflammatory  affection  of  the 
dura  mater,  characterized  by  severe  pains  in  the  head,  shoul- 
ders, arms,  and  loins,  followed  by  paresis,  wasting,  and 
anesthesia. 

!^tiology. — Prolonged  exposure  to  cold,  spinal  concus- 
sion, alcoholism,  and  syphilis  are  predisposing  factors.  It 
may  be  secondary  to  inflammation  of  neighboring  structures, 
such  as  the  vertebrae  in  Pott's  disease. 

Pathology. — The  membranes  are  thickened,  opaque,  and 


ACUTE   MYELITIS.  405 

adherent ;  the  vessels  are  dilated ;  and  the  spinal  fluid  is 
increased.  In  advanced  cases  the  membranes  are  glued 
together  and  form  a  thick,  homogeneous,  fibrous  mass.  The 
cervical  region  is  most  commonly  affected.  The  inflamma- 
tion may  extend  to  the  cord  and  peripheral  nerves. 

Symptoms. — These  include  sharp  pains  radiating  into 
the  head,  shoulders,  arms,  and  loins,  and  paresthesia,  fol- 
lowed by  loss  of  power,  anesthesia,  wasting,  and  rigidity, 
particularly  in  the  upper  extremities.  ■  When  the  lower  part 
of  the  cord  is  involved,  the  same  phenomena  are  observed 
in  the  legs,  and  the  knee-jerk  is  increased.  The  duration  of 
the  disease  is  several  years. 

Diagnosis. — Chronic  Poliomyelitis. — The  absence  of  pain 
and  of  anesthesia  will  separate  poliomyelitis  from  pachy- 
meningitis. 

Multiple  Neuritis. — In  this  affection  the  pain  is  less  marked 
in  the  back  and  more  marked  in  the  extremities,  and  the 
nerve-trunks  are  tender  on  pressure. 

Syringomyelia. — In  this  affection  there  is  much  less  pain 
and  tactile  sensation  is  preserved. 

Prognosis. — This  depends  on  the  extent  and  cause. 
When  the  involvement  is  slight  or  is  due  to  syphilis,  the 
prognosis  should  be  guardedly  favorable. 

Treatment. — Counterirritation  should  be  made  along 
the  cord  by  frequent  bUsters  or  the  actual  cautery.  lodid 
of  potassium  may  be  administered  for  its  absorbent  effect, 
and  in  syphilitic  cases  it  should  be  given  freely  in  conjunc- 
tion with  some  mercurial. 

ACUTE  MYELITIS. 

Definition. — An  acute  inflammation  of  the  substance  of 
the  cord,  characterized  by  marked  disturbances  of  motion, 
sensation,  and  nutrition. 

Varieties. — When  only  a  limited  vertical  area  of  the 
spinal  cord  is  involved,  the  condition  is  termed  trmisversc 
myelitis.  When  a  large  vertical  section  is  affected,  the  dis- 
ease is  termed  diffuse  myelitis. 

]^tiology. — Traumatism,  exposure,  or  overexertion  may 


406  DISEASES   OF   THE   NERVOUS  SYSTEM. 

induce  it.  It  may  be  a  sequel  of  syphilis  or  of  an  acute 
infectious  disease,  such  as  smallpox,  typhoid  fever,  pneu- 
monia, dysentery,  or  gonorrhea.  It  is  sometimes  secondary 
to  caries  of  the  spine  or  tumors  of  the  cord. 

Pathology. — The  membranes  are  usually  injected  and 
opaque.  The  substance  of  the  cord  is  red  and  soft,  and  the 
line  of  demarcation  between  the  gray  and  white  matter  is 
indistinct.  In  very  acute  cases  the  substance  of  the  cord 
may  flow  out  as  a  reddish,  creamy  fluid  when  the  mem- 
branes are  cut.  Occasionally  there  are  conspicuous  hemor- 
rhagic effusions  (hematomyelitis). 

Microscopically,  the  bloodvessels  are  found  to  be  greatly 
dilated  and  surrounded  by  leukocytes  ;  the  myelin  sheaths 
swollen  and  fatty;  the  axis-cylinders  swollen,  granular,  and 
perhaps  disintegrated ;  and  the  nerve-cells  necrotic,  vacuo- 
lated, and  in  places  without  processes.  In  the  severe  cases 
in  which  the  cord  is  reduced  to  a  puriform  mass  examina- 
tion reveals  only  fat  droplets,  pigment  particles,  granular 
cells,  leukocytes,  and  detritus. 

Symptoms. — Acute  Transverse  Myelitis. — The  onset  is 
frequently  marked  by  pains  in  the  back,  a  girdle  sensation, 
and  numbness  in  the  limbs.  Paralysis  and  anesthesia  of 
the  parts  below  the  lesion  quickly  develop.  The  control  of 
the  bladder  and  rectum  is  lost.  Bed-sores  are  apt  to  form 
over  the  sacrum  and  heels.  Of  the  paralyzed  muscles  only 
those  supplied  by  nerves  arising  from  the  diseased  segment 
undergo  atrophy  and  yield  reactions  of  degeneration.  The 
knee-jerks  are  usually  increased  and  the  legs  stiff  and  rigid. 
There  may  be  a  loss  of  tendon  reflexes  with  flaccidity  of 
the  muscles,  however,  if  the  cord  is  entirely  divided  (Bas- 
tian)  or  if  the  lesion  invades  the  lumbar  segments.  There 
is  often  a  zone  of  hyperesthesia  just  above  the  level  of  the 
anesthesia.     Fever  may  or  may  not  be  present. 

The  outlook  is  always  serious.  More  or  less  disability 
usually  remains  after  the  subsidence  of  the  inflammation. 
Complete  recovery  may  occur,  however,  in  mild  cases.  Not 
rarely  death  ensues  from  cystitis  and  pyelonephritis,  bed- 
sores and  sepsis,  or  pneumonia. 

Acute  Central  Myelitis. — This  resembles  the  former,  but 


ACUTE   MYELITIS.  407 

the  trophic  disturbances  are  much  more  marked  and  the 
duration  is  shorter.  The  disease  is  characterized  by  moderate 
fever  and  its  associated  phenomena,  pain  in  the  back,  com- 
plete loss  of  power  and  of  sensation,  loss  of  reflexes,  incon- 
tinence of  urine  and  feces,  rapid  wasting  of  the  muscles,  and 
the  early  development  of  bed-sores.  The  disease  frequently 
proves  fatal  in  from  one  to  two  weeks. 

Diagnosis. — Acute  Poliomyelitis. — In  this  disease  the 
bladder  and  rectum  are  not  involved  and  there  are  no  sen- 
sory disturbances. 

Landry's  Disease  or  Acute  Ascending  Paralysis. — In  this 
affection  trophic  disturbances  are  absent ;  the  bladder  and 
rectum  are  not  involved ;  and  the  loss  of  sensation  is  slight. 

Multiple  Neuritis. — The  "  girdle  pain  "  is  absent ;  the 
sphincters  are  not  affected  ;  bed-sores  are  rare  ;  and  pain  is 
more  marked  in  the  extremities  than  in  the  back. 

Meningitis. — The  girdle  pain  is  absent ;  the  sphincters  are 
not  affected ;  the  irritative  phenomena  are  more  marked  than 
the  paralytic. 

Hemorrhage  into  the  Cord. — The  paralysis  develops  ab- 
ruptly. 

Prog^nosiS. — Always  extremely  grave.  Acute  central 
myelitis  is  invariably  fatal.  In  other  cases  recovery  attended 
with  partial  paralysis  occasionally  follows. 

Treatment. — If  possible,  the  patient  should  be  placed  on 
a  water-bed  or  air-bed.  Counterirritation  should  be  avoided, 
on  account  of  the  danger  of  bed-sores.  Cold,  however,  in 
the  form  of  Chapman's  ice-bags,  may  be  appHed  to  the 
spine.  Daily  warm  baths  (90°  F.)  lasting  about  ten  minutes 
are  useful. 

Every  precaution  must  be  taken  against  the  development 
of  bed-sores.  Frequent  change  of  the  patient's  position, 
absolute  cleanliness  of  the  parts  subjected  to  pressure,  and 
bathing  with  alcohol  and  water  will  do  much  toward  ob- 
viating this  complication.  Retention  of  urine  must  be  met 
by  systematic  catheterization  under  the  most  strict  antiseptic 
precautions.  When  there  is  constant '  incontinence,  a  care- 
fully adjusted  urinal  should  be  employed. 

Any  tendency  to  cystitis  will  call  for  daily  irrigation  of 


408  DISEASES   OF   THE   NERVOUS  SYSTEM. 

the  bladder  with  a  solution  of  boric  acid  or  other  mild  anti- 
septic solution.  If  recovery  with  partial  paralysis  result, 
massage  and  electricity  may  aid  in  bringing  back  some  of 
the  lost  power. 

CHRONIC  MYELITIS. 

Etiolog^y. — Traumatism,  exposure,  alcoholism,  and 
syphilis  are  predisposing  factors.  It  is  sometimes  induced 
by  the  extension  of  inflammation  from  adjacent  structures — 
meninges  and  vertebrae.  It  is  occasionally  a  sequel  of  acute 
myehtis. 

Pathology. — The  membranes  are  opaque  and  adherent. 
The  whole  cord  has  a  grayish  color  ;  it  is  firmer  than  nor- 
mal and  somewhat  contracted. 

Microscopic  examination  reveals  destruction  of  nerve  ele- 
ments and  their  replacement  by  an  overgrowth  of  neurog- 
liar  tissue. 

Symptoms. — The  disease  begins  gradually  with  numb- 
ness, tingling,  or  burning  in  the  lower  extremities,  followed 
by  a  loss  of  power  and  sensation.  The  reflexes  are  gener- 
ally exaggerated.  The  sphincters  soon  become  involved. 
The  muscles  do  not  waste  until  the  disease  is  far  advanced. 
As  in  other  organic  affections  of  the  cord,  there  is  often  a 
sense  of  constriction,  or  "  girdle  pain,"  at  the  level  of  the 
disease.  The  disease  progresses  very  slowly,  the  duration 
being  from  six  months  to  ten  years. 

Diagnosis. — The  diagnosis  rests  on  the  gradual  devel- 
opment of  symptoms  indicating  a  general  involvement  of 
the  cord. 

Treatment. — Prolonged  rest  is  desirable.  Daily  warm 
baths  are  grateful.  Counterirritation  in  the  form  of  light 
touches  of  the  actual  cautery  is  useful  in  relieving  pain,  but 
it  does  not  seem  to  exert  any  direct  influence  on  the  prog- 
ress of  the  disease.  When  there  is  reason  to  suspect  the  ex- 
istence of  syphilis,  mercury  and  the  iodids  should  be  given 
a  thorough  trial.  Tonics  are  often  indicated.  Massage, 
passive  movements,  and  electricity  are  useful  in  maintaining 
the    nutrition    of    the   affected    muscles.     Early   measures 


ACUTE  ANTERIOR   POLIOMYELITIS.  409 

should  be  taken  to  prevent  the  formation  of  bed-sores  and 
the  development  of  cystitis. 

ACUTE  ANTERIOR  POLIOMYELITIS- 

(Infantile  Paralysis;  Atrophic  Spinal  Paralysis.) 

Definition. — An  acute  disease,  occurring  almost  exclu- 
sively in  young  children,  characterized  anatomically  by  a 
destruction  of  the  ganglion-cells  in  the  anterior  gray  horns 
of  the  cord,  and  manifested  clinically  by  abrupt  paralysis 
and  rapid  wasting  of  certain  muscles. 

!^tiology. — The  greatest  number  of  cases  occur  within 
the  first  three  years,  and  the  disease  is  far  more  common  in 
summer  than  in  winter.  The  sudden  onset,  the  absence  of 
any  known  exciting  cause,  and  the  fact  that  it  has  occurred 
endemically  suggest  an  infectious  origin. 

Pathology. — Microscopic  examination  of  the  cord  in 
early  cases  reveals  great  distention  of  the  vessels,  cellular 
infiltration  of  the  perivascular  spaces,  and  degeneration  and 
disintegration  of  the  ganglion  cells.  These  lesions  are 
probably  due  to  occlusion  of  certain  branches  of  the  anterior 
spinal  artery  by  thrombi  of  infective  origin. 

In  old  cases  the  lesions  found  consist  of  a  marked 
atrophy  of  the  anterior  horn,  an  absence  of  ganglion  cells, 
and  increase  of  the  neuroglia. 

The  motor  nerve-fibers  corresponding  to  the  diseased 
segment  and  the  muscle-fibers  innervated  by  these  nerves 
also  show  degenerative  changes. 

Symptoms. — Generally  the  onset  is  abrupt;  often  the 
child  is  put  to  bed  in  apparent  health  and  in  the  morning  is 
found  paralyzed  in  one  or  more  limbs.  In  some  cases 
febrile  symptoms  precede  the  attack,  and  more  rarely  the 
disease  is  ushered  in  with  a  chill,  a  convulsion,  or  delirium. 

The  paralysis  at  first  may  be  quite  extensive,  but  more 
commonly  it  confines  itself  to  certain  groups  of  muscles  in 
the  upper  or  lower  extremities.  The  latter  are  especially 
prone  to  suffer ;  the  affected  muscles  are  relaxed,  and  the 
surface  is  cold  and  often  cyanosed.  The  paralysis  is  pecu- 
liar in  its  irregular  distribution  and  in  its  tendency  to  im- 


4IO  DISEASES   OF   THE   NERVOUS  SYSTEM. 

prove  spontaneously  up  to  a  certain  limit.  There  are  no 
sensory  disturbances,  no  involvement  of  the  bladder  and 
rectum,  and  no  tendency  to  bed-sores.  The  muscles  that 
are  permanently  affected  rapidly  waste  and  ultimately  yield 
the  reactions  of  degeneration.  Permanent  deformity  often 
ensues  from  the  ratardation  of  growth  in  the  paralyzed 
limb  and  the  occurrence  of  contractures  in  the  unaffected 
muscles. 

Diagnosis. — The  abrupt  onset  will  distinguish  it  from 
both  the  muscular  dystrophies  and  chronic  poliomyelitis.  The 
absence  of  sensory  disturbances,  bed-sores,  and  paralysis  of 
the  bladder  and  rectum  will  distinguish  it  from  myelitis. 
The  presence  of  cerebral  symptoms  and  of  exaggerated 
reflexes,  and  the  absence  of  reactions  of  degeneration  and 
of  early  wasting  will  distinguish  cerebral  paralysis  of  child- 
hood from  acute  poliomyelitis. 

Prognosis. — Unless  the  initial  symptoms  are  very  severe, 
the  prognosis  as  regards  life  is  good.  In  all  cases  some  of 
the  paralysis  disappears.  Occasionally  the  improvement  is 
so  great  that  the  usefulness  of  the  member  is  not  impaired ; 
but  far  more  frequently  the  residual  paralysis  is  sufficient  to 
cause  considerable  deformity  and  disability. 

Treatment. — During  the  acute  stage  the  child  should 
be  confined  to  bed.  Mild  laxatives  and  febrifuges  may  be 
used  with  some  advantage.  Ergot  is  often  given  with  the 
view  of  lessening  congestion,  but  it  is  of  doubtful  utility. 
The  affected  limbs  should  be  wrapped  in  cotton-wool. 
After  the  lapse  of  two  or  three  weeks,  electric  treatment 
should  be  instituted.  As  faradism  generally  fails  to  elicit 
any  response,  recourse  must  be  had  to  an  interrupted  gal- 
vanic current.  One  pole  (cathode)  may  be  placed  over  an 
indifferent  point,  such  as  the  spine,  while  the  other  (anode) 
is  slowly  stroked  over  the  affected  muscles,  The  weakest 
current  that  will  cause  contraction  should  be  used.  The 
treatment  should  be  given  for  ten  minutes,  three  or  four 
times  weekly,  and  should  be  kept  up,  if  necessary,  for 
several  months.  Massage  is  a  valuable  adjuvant  to  electric 
treatment.  Local  bathing  with  shampooing  may  also  be  used 
with  benefit.      Internally  strychnin  (y^  of  a  grain,  grad- 


CHRONIC  ANTERIOR   POLIOMYELITIS.  4II 

ually  increased,  to  a  child  of  two  years)  is  sometimes  use- 
ful. The  treatment  of  the  latter  stages  of  infantile  paralysis 
is  chiefly  surgical,  and  has  for  its  object  the  prevention  or 
correction  of  deformities. 


CHRONIC    ANTERIOR    POLIOMYELITIS— PRO- 
GRESSIVE MUSCULAR  ATROPHY. 

(Chronic  Spinal  Muscular  Atrophy  of  Aran-Duchenne.) 

Definition* — A  chronic  disease  characterized  anatomic- 
ally by  atrophy  of  the  ganglion-cells  in  the  anterior  gray 
horns  of  the  spinal  cord,  and  manifested  cHnically  by  a 
progressive  wasting  of  the  muscles  and  a  corresponding 
loss  of  power. 

]^tiolog"y. — The  disease  is  much  more  common  in  males 
than  in  females.  It  occurs  most  frequently  in  adults 
between  the  ages  of  twenty  and  fifty.  Heredity  is  rarely  a 
factor.  Exposure,  overexertion,  mental  strain,  injury,  and 
syphilis  have  been  mentioned  as  causes. 

Pathology. —  Microscopic  examination  of  the  cord 
reveals  atrophy  or  entire  absence  of  the  ganglion  cells  in 
the  anterior  cornua  and  an  overgrowth  of  the  neuroglia. 
The  anterior  nerve-roots,  peripheral  motor  nerve-fibers,  and 
affected  muscles  also  show  degenerative  atrophy. 

In  addition  to  these  lesions,  there  is  often  sclerosis  of 
anterolateral  white  tracts   (amyotrophic  lateral  sclerosis). 

Symptoms. — The  onset  is  insidious.  The  muscles  of 
the  hand  usually  suffer  first.  The  thenar  and  the  hypo- 
thenar  eminences  and  the  interosseous  muscles  become 
more  flaccid  than  normal  and  gradually  waste.  Accom- 
panying the  atrophy  there  is  a  corresponding  loss  of  mus- 
cular power.  When  the  interossei  no  longer  afford 
opposition  to  the  long  flexor  and  extensor  muscles,  the 
hand  assumes  a  claw-like  position  (main  en  griffc),  which  is 
quite  characteristic.  Fine  fibrillary  tremors  or  twitchings 
are  almost  invariably  present  in  the  affected  muscles.  After 
the  lapse  of  months,  perhaps  years,  the  wasting  and  paresis 
spread  to  the  muscles  of  the  shoulder  and  arm,  and  then 


412  DISEASES   OF  THE   NERVOUS  SYSTEM. 

to  the  neck  and  trunk.  The  legs  are  usually  not  involved 
until  late,  and  often  escape  entirely.  Occasionally,  however, 
the  disease  begins  in  the  lower  extremities  or  back,  but  this 
is  rare.  In  the  late  stages  the  patient  may  be  reduced  to  a 
mere  skeleton.  Sometimes  the  process  extends  to  the 
medulla,  in  which  case  the  symptoms  of  bulbar  palsy  are 
superadded. 

There  may  be  some  complaint  of  coldness  or  of  dull 
pain,  but  sensation  is  not  impaired.  The  deep  reflexes  are 
lost  in  the  affected  limbs  and  the  paralyzed  muscles  remain 
flaccid.  The  reactions  of  degeneration  are  sometimes  pres- 
ent, but  more  often  there  is  simply  diminished  response 
first  to  the  faradic  and  then  to  the  galvanic  current.  The 
sphincters  are  not  involved. 

Diagnosis. —  Chronic  poliomyelitis  must  be  distin- 
guished from  other  conditions  causing  slowly  progressing 
atrophy  and  weakness,  such  as  amyotrophic  lateral  sclerosis, 
muscular  dystrophy,   multiple  neuritis,  and  syringomyelia. 

Amyotrophic  Lateral  Sclerosis. — In  this  disease  the  wasting 
is  associated  with  spastic  rigidity  and  the  tendon-reflexes 
are  exaggerated. 

Muscular  Dystrophy. — This  is  commonly  an  hereditary  or 
a  family  affection.  It  occurs  in  childhood  and  attacks  pri- 
marily large  muscles  (calf,  shoulder  girth,  or  face).  There 
is  no  fibrillary  twitching. 

Multiple  Neuritis. — In  this  disease  the  paralysis  precedes 
the  wasting.  Sensory  symptoms  are  usually  prominent, 
and  there  is  often  tenderness  along  the  nerve-trunks. 

Syringomyelia. — In  this  affection  the  atrophy  is  accom- 
panied by  exaggerated  reflexes,  peculiar  sensory  disturb- 
ances, and  trophic  changes  in  the  skin  and  joints. 

Prognosis  and  Treatment. — The  course  of  the  dis- 
ease is  very  slow  and  occasionally  marked  by  remissions. 
Death  may  result  from  involvement  of  the  respiratory 
muscles,  aspiration  pneumonia,  or  bulbar  palsy.  Treatment 
is  of  no  avail. 


PRIMARY  SPASTIC  PARAPLEGIA.  413 

PRIMARY  SPASTIC  PARAPLEGIA* 

(Lateral  Sclerosis;   Anterolateral  Sclerosis.) 

Definition. — A  chronic  disease,  characterized  by  gradual 
loss  of  power,  marked  exaggeration  of  the  reflexes,  and  a 
spastic  condition  of  the  muscles,  without  atrophy  or  sensory 
disturbances. 

Btiology. — The  etiology  is  obscure.  The  disease  usually 
develops  between  the  ages  of  twenty  and  forty.  Both  sexes 
are  equally  affected. 

Pathology. — A  primary  degeneration  of  the  lateral 
pyramidal  tracts  (terminations  of  the  upper  motor  neurons) 
is  assumed  to  be  the  anatomic  cause  of  the  disease. 

Symptoms. — Loss  of  power  is  generally  the  first  symp- 
tom. This  begins  in  the  lower  extremities  and  increases 
very  slowly.  The  knee-jerk  is  exaggerated,  and  in  most 
cases  ankle-clonus  can  be  elicited.  When  put  in  use,  the 
muscles  become  stiff  or  spastic,  and  when  the  disease  is 
fully  developed,  the  gait  is  peculiar.  In  walking  the  knees 
are  drawn  together,  the  legs  drag  behind,  and  the  toes  catch 
the  ground. 

The  muscles  do  not  waste,  but  tend  rather  to  become 
hypertrophied  from  continued  reflex  stimulation.  Sensory 
and  trophic  disturbances  are  absent,  and  the  sphincters  are 
only  rarely  aflected. 

Diagnosis. — As  an  independent  affection  lateral  sclerosis 
is  rare,  spastic  paralysis  of  the  legs  generally  being  due 
to  ( I )  diseases  of  the  brain  involving  both  motor  tracts,  as  in- 
fantile cerebral  palsy  or  (2)  diseases  of  the  spinal  cord  divid- 
ing the  lateral  columns,  such  as  multiple  sclerosis,  tumors 
of  the  cord,  compression  in  Pott's  disease,  transverse  myel- 
itis, etc. 

Prognosis. — The  disease  is  incurable,  but  the  course  is 
extremely  slow. 

Treatment. — Rest,  warm  baths  (90°  F.),  and  massage 
are  the  most  useful  measures.  If  there  be  a  suspicion  of 
syphilis,  antiluetic  treatment  should  be  instituted, 


414  DISEASES    OF   THE   NERVOUS   SYSTEM. 

AMYOTROPHIC  LATERAL  SCLEROSIS* 

Definition. — A  chronic  disease,  characterized  anatomi- 
cally by  degeneration  of  the  lateral  columns  and  atrophy 
of  the  ganglionic  cells  in  the  anterior  gray  horns  of  the 
spinal  cord,  and  clinically  by  loss  of  power,  atrophy,  and  a 
spastic  state  of  the  muscles. 

Pathology. — The  chief  lesion  is  a  degeneration  of  the 
pyramidal  tracts,  with  atrophy  of  the  large  cells  in  the  ven- 
tral horns  and  of  certain  groups  of  cells  in  the  medulla. 

Symptoms. — These  include  wasting  of  the  muscles, 
with  loss  of  power,  spastic  contractions,  and  exaggerated 
reflexes.     The  upper  extremities  are  usually  first  affected. 

When  the  medulla  is  involved,  symptoms  of  glossolabial 
paralysis  appear.  Sensation  is  not  impaired,  and  the  sphinc- 
ters are  rarely  disturbed. 

The  muscular  rigidity  and  exaggerated  reflexes  will  dis- 
tinguish it  from  pure  progressive  vnisciilar  atrophy,  and  the 
atrophy  of  the  muscles  from  pure  lateral  sclerosis. 

Prognosis. — Unfavorable.  Death  occurs  in  from  two 
to  ten  years. 

Treatment. — This  is  the  same  as  for  lateral  sclerosis. 

BULBAR  PARALYSIS 

(Glossolabiolaryngeal  Paralysis.) 

Definition. — Paralysis  of  the  lips,  tongue,  pharynx,  and 
larynx  from  degeneration  of  the  motor  nuclei  of  the  me- 
dulla oblongata. 

!^tiology. — An  acute  form  is  observed  that  results  either 
from  hemorrhage  or  from  an  acute  poliomyelitis  of  the  me- 
dulla. The  chronic  form  is  essentially  a  chronic  poliomye- 
litis of  the  bulb.  It  may  occur  as  an  independent  disease, 
but  more  often  it  is  a  part  of  amyotrophic  lateral  sclerosis 
or  progressive  muscular  atrophy. 

Symptoms. — These  include  impairment  of  speech  ;  in- 
ability to  protrude  the  tongue  ;  dribbling  of  saliva  ;  difficult 
swallowing;   choking  spells  from  the  entrance  of  food  or 


ACUTE  ASCENDING   PARALYSIS.  415 

mucus  into  the  larynx ;  partial  suppression  of  the  voice 
with  measured  speaking-;  and  a  lack  of  facial  expression. 
The  paresis  is  attended  by  atrophy  and  fibrillary  tremors. 

In  the  rare  disease  known  as  pseudobulbar  paralysis, 
which  results  from  bilateral  lesions  in  the  motor  cortex  or 
internal  capsule,  there  i^  usually  some  mental  impairment 
and  aphasia,  and  the  paralysis  is  not  accompanied  by 
atrophy  and  fibrillary  tremors. 

Prognosis. — Unfavorable.  The  acute  variety  is  speedily 
fatal ;  the  chronic  form  may  last  several  years.  Death  may 
result  from  exhaustion,  cardiac  failure,  or  aspiration-pneu- 
monia. 

Treatment. — This  is  unsatisfactory.  Massage  and  elec- 
tricity may  be  tried.  Strychnin  has  been  recommended. 
The  stomach-tube  should  be  used  when  the  patient  is  unable 
to  swallow. 

ACUTE  ASCENDING  PARALYSIS* 

(Landry's  Disease.) 

Definition. — An  .acute  disease  of  rare  occurrence,  char- 
acterized by  motor  paralysis  beginning  in  the  feet  and 
rapidly  spreading  until  it  involves  the  muscles  of  respira- 
tion and  deglutition. 

Htiology. — The  causes  are  unknown.  It  is  usually  ob- 
served in  young  male  adults.  The  abrupt  onset,  acute 
course,  and  absence  of  known  cause  and  of  definite  lesions 
have  suggested  toxic  origin. 

Pathology. — In  a  few  instances  degenerative  changes 
have  been  detected  in  the  lower  motor  neurons. 

Symptoms. — Febrile  symptoms  usually  usher  in  the 
attack.  The  paralysis  begins  in  the  legs  and  involves  suc- 
cessively the  trunk,  upper  extremities,  and  muscles  of 
respiration  and  deglutition.  The  reflexes  are  abolished. 
The  sphincters  are  retentive  ;  sensation  is  usually  normal, 
but  there  may  be  some  paresthesia  ;  the  muscles  are  relaxed, 
but  do  not  waste  or  yield  the  reactions  of  degeneration. 
In  some  instances  the  spleen  and  lymphatic  glands  are 
swollen. 


4l6  DISEASES   OF  THE   NERVOUS  SYSTEM. 

Diagnosis. — Acute  Myelitis. — Anesthesia,  wasting,  reac- 
tions of  degeneration,  and  early  involvement  of  the  sphinc- 
ters will  serve  to  distinguish  myelitis  from  acute  ascending 
paralysis. 

Multiple  neuritis  can  usually  be  distinguished  from  Landry's 
disease  by  the  marked  sensory  disturbances  in  the  former. 

Prognosis. — Unfavorable.  The  vast  majority  of  cases 
terminate  fatally  in  from  a  few  days  to  two  or  three  weeks. 
Very  rarely  the  disease  comes  to  a  standstill  and  a  slow 
recovery  ensues. 

Treatment. — The  patient  should  be  kept  at  rest,  and 
wet  cups  applied  to  the  spine.  Ergotin  (lo  to  20  grains  a 
day),  belladonna,  salicylates,  mercury,  and  iodids  are  the 
remedies  that  have  been   recommended. 

LOCOMOTOR  ATAXIA. 

(Tal)es  Dorsalis  ;  Posterior  Spinal  Sclerosis.) 

Definition. — A  degenerative  affection  of  the  posterior 
columns  of  the  spinal  cord  and  posterior  nerve-roots,  char- 
acterized by  incoordination,  loss  of  deep  reflexes,  disturbances 
of  sensation  and  nutrition,  and  various  ocular  phenomena. 

etiology. — The  disease  occurs  most  frequently  between 
the  ages  of  thirty  and  fifty.  It  is  ten  times  more  common 
in  men  than  in  women.  Syphilis  appears  to  be  the  exciting 
cause  of  at  least  three-fourths  of  all  cases.  Exposure,  ex- 
cesses, overexertion,  and  alcoholism  are  contributing  factors. 

Pathology. — The  pia  mater  over  the  posterior  columns 
is  somewhat  thickened  and  opaque.  The  posterior  columns 
have  a  grayish  color  and  are  firm  and  shrunken. 

Microscopic  examination  reveals ,  atrophy  of  the  nerve- 
fibers  and  overgrowth  of  neuralgia  in  the  columns  of  Goll 
and  Burdach.  The  posterior  nerve-roots  are  invariably  de- 
generated. The  spinal  ganglia  may  or  may  not  be  in- 
volved. In  many  cases  the  sensory  nerves  of  the  periphery 
and  the  cranial  nerves,  especially  the  optic,  exhibit  degen- 
erative changes. 

Symptoms. — Motor  Phenomena. — One  of  the  earliest 
symptoms  is  loss  of  coordination.     This  is  first  manifested 


LOCOMOTOR   ATAXIA.  417 

by  unsteadiness  when  the  patient  walks  in  the  dark.  When 
he  stands  erect,  with  the  eyes  closed  and  feet  together,  he 
staggers  and  tends^  to  fall  (Romberg's  symptom).  When 
the  arms  are  affected,  there  is  inability  to  perform  work  re- 
quiring delicate  coordination,  such  as  writing  and  piano- 
playing.  This  loss  of  coordination  in  the  upper  extremities 
becomes  conspicuous  when  the  patient,  while  his  eyes  are 
closed,  attempts  to  touch  the  tip  of  his  nose. 

The  gait  is  characteristic ;  in  walking  he  raises  his  feet 
high,  throws  them  forward,  and  brings  them  down  forcibly 
in  such  a  way  that  the  whole  sole  strikes  the  floor  at  once. 
Although  the  patient  may  be  unable  to  walk  or  to  use  his 
hands  with  precision,  there  is  very  little  loss  of  power.  A 
peculiar  relaxation  of  the  muscles  with  an  unusual  mobihty 
of  the  joints  (hypotonia)  is  not  uncommon. 

Sensory  Phenomena. — Pain  is  rarely  absent;  it  is  sharp 
and  lancinating  in  character,  and  appears  in  paroxysms.  It 
usually  involves  the  extremities,  but  sometimes  it  attacks  the 
stomach  and  is  accompanied  with  obstinate  vomiting.  The 
term  gastric  crisis  is  applied  to  this  phenomenon.  Crises 
may  also  occur  in  other  organs,  notably  the  larynx,  where 
they   are   manifested   by   intense   dyspnea    and    stridulous 

breathing. 

A  sense  of  constriction  about  the  trunk  at  different  levels 
("  girdle  sensation  ")  is  a  common  sensory-  symptom.  Various 
forms  of  paresthesia  are  observed,  such  as  tingling,  numb- 
ness, burning,  etc.  Irregular  areas  of  anesthesia  are  nearly 
always  present.  The  muscle-sense  is  also  more  or  less  im- 
paired. 

Reflex  Phenomena.— ^\v^  knee-jerk  is  lost  early  in  the 
disease.  Later  other  reflexes,  such  as  the  plantar,  cremas- 
teric, and  abdominal,  may  be  abolished. 

Eye  Phenome?ia. — The  pupil  fails  to  respond  to  light  while 
it  still  accommodates  for  distance  (Argyll-Robertson  pupil). 
The  pupils  are  usually  small.  Optic-nerve  atrophy  and 
paresis  of  the  ocular  muscles  are  frequent  symptoms. 

Visceral  Phenomena.— h^^^.x^  from  the  crises  already  men- 
tioned, there  may  be  incontinence  of  urine,  constipation,  or 
paralysis  of  the  sphincter  ani,  and  loss  of  sexual  power. 
27 


41 8  DISEASES   OF  THE  NERVOUS  SYSTEM. 

Trophic  Phenomena. — These  usually  appear  late.  The 
most  curious  are  the  so-called  arthropathies,  which  consist 
of  enlargement  of  the  joints,  associated  with  serous  effusions, 
atrophy  of  the  heads  of  the  bone,  erosion  of  the  cartilages, 
and  calcification  of  the  ligaments.  These  articular  changes 
sometimes  lead  to  luxations.  Occasionally  a  perforating 
ulcer  appears  in  the  foot. 

Mental  Phenomena. — In  many  cases  symptoms  of  paretic 
dementia  ultimately  supervene. 

Diagnosis.— Multiple  Neuritis. — In  this  disease  the  onset 
is  rapid,  eye-symptoms  and  lightning  pains  are  absent,  the 
bladder  is  rarely  affected ;  while,  on  the  other  hand,  there 
is  an  actual  loss  of  muscular  power,  with  wasting  of  the 
muscles  and  diminished  electric  excitability. 

Cerebellar  Disease. — In  lesions  of  the  cerebellum  the  knee- 
jerks  are  usually  retained,  the  pupils  react  to  light,  light- 
ning pains  and  other  sensory  disturbances  are  wanting, 
while  headache,  vertigo,  optic  neuritis,  and  vomiting  are 
prominent  symptoms. 

Gastralgia. — A  gastric  crisis  may  be  mistaken  for  gas- 
tralgia,  but  the  associated  phenomena  of  locomotor  ataxia 
will  prevent  an  error  in  diagnosis. 

Prognosis. — Complete  recovery  probably  never  occurs. 
The  duration  ranges  from  three  to  twenty  years.  Death  is 
usually  the  result  of  some  intercurrent  disease. 

Treatment. — Rest  is  an  important  factor  in  the  treatment. 
Erb  advises  that  the  patient  should  live  as  \{  he  were  an 
old  man,  quietly,  regularly,  and  with  no  excitement.  Mental 
fatigue  should  also  be  avoided.  Sexual  excesses  are  exceed- 
ingly injurious.  The  diet  should  be  nutritious  and  easily 
digestible.  Alcohol  and  tobacco  should  be  used  sparingly, 
if  at  all.     Flannel  should  always  be  worn  next  to  the  skin. 

Massage  affords  a  valuable  means  of  securing  the  benefits 
of  exercise  without  the  expenditure  of  energy. 

Systematic  reeducation  of  coordinating  movements,  as 
originally  recommended  by  Frenkel,  has  been  found  a  most 
effective  remedy  for  the  ataxia.  Even  in  advanced  cases,  in 
which  there  is  marked  disturbance  of  sensation,  this  method 
of  treatment  is  not  without  benefit,  and  the  improvement 


ATAXIC  PARAPLEGIA.  419 

may  last  for  years  if  the  disease  is  stationary  or  only  slowly 
progressive. 

Tepid  baths  of  8o°-85°  F.  are  sometimes  of  distinct  ser- 
vice. They  should  be  suspended,  however,  while  the  exer- 
cise treatment  is  being  used.  Mercury  and  iodids  should 
be  given  a  thorough  trial  in  all  cases  in  which  syphilis  is 
suspected. 

Tlie  Pams. — When  the  pains  are  severe,  the  most  potent 
remedial  measure  is  absolute  rest  in  bed.  Light  touches  of 
the  actual  cautery  or  sinapisms  over  the  root  of  the  nerve 
supplying  the  affected  part  often  afford  relief  Deep  massage 
is  sometimes  of  service.  Mitchell  has  found  the  alternate 
application  of  ice  and  hot  water  useful.  Flannel  bandages 
applied  firmly  from  the  toes  up  to  the  middle  third  of  the 
thigh  sometimes  do  much  good.  A  snugly  fitting  abdominal 
binder  may  also  be  used  to  lessen  girdle  pain.  Electricity 
in  the  form  of  the  faradic  brush,  static  spark,  or  stabile  gal- 
vanic anode  is  worthy  of  a  trial. 

The  most  generally  useful  anodynes  are  phenacetin  and 
antipyrin.  Cannabis  indica  or  nitroglycerin  occasionally 
succeeds. 

In  many  cases  recourse  must  be  had  to  morphin,  but  its 
use  should  be  deferred  as  long  as  possible. 

Numbness  and  paresthesia  often  yield  for  a  time  to  local 
applications  of  faradism  given  with  the  wire  brush. 

Vesical  weakness  should  receive  the  most  careful  attention. 
The  bladder  must  be  thoroughly  emptied — if  need  be,  by 
catheterization.  On  the  first  appearance  of  cystitis  the 
bladder  should  be  thoroughly  washed  out  with  weak  anti- 
septic solutions. 

ATAXIC  PARAPLEGIA^ 

Definition. — A  sclerotic  affection  of  the  posterior  and 
lateral  columns,  manifesting  symptoms  of  both  locomotor 
ataxia  and  spastic  paraplegia. 

Symptoms. — It  resembles  spastic  paraplegia  in  the  loss 
of  power,  spastic  condition  of  the  muscles,  increased  re- 
flexes, and  absence  of  ocular  and  sensory  disturbances  ;  and 
locomotor  ataxia  in  the  distinct  loss  of  coordination. 


420  DISEASES   OE   THE   NERVOUS  SYSTEM. 

DISSEMINATED  CEREBROSPINAL  SCLEROSIS. 

(Multiple  Sclerosis;  Insular  Sclerosis.) 

Definition. — A  chronic  disease,  characterized  anatomi- 
cally by  patches  of  sclerosis  of  varying  size  scattered  through- 
out the  brain  and  spinal  cord. 

Btiology. — The  causes  that  lead  to  other  scleroses  of 
the  spinal  cord  may  induce  this  disease;  the  infectious 
fevers,  however,  are  assigned  a  prominent  place  in  its  eti- 
ology. It  is  a  disease  of  youth,  the  majority  of  cases  oc- 
curring between  the  tenth  and  thirtieth  years. 

Patholog"y. — Areas  of  firm,  gray,  sclerotic  tissue,  of 
various  sizes  and  shapes,  are  found  through  the  brain  and 
spinal  cord. 

Symptoms. — The  symptoms  develop  slowly  and  are 
variable.  The  most  characteristic  are  :  (i)  A  coarse  tremor, 
which  affects  chiefly  the  arms  and  head,  which  is  brought 
on  by  muscular  effort,  and  which  ceases  during  complete 
rest  (volitional  or  intention  tremor)  ;  (2)  nystagmus,  or  oscil- 
lation of  the  eye-balls ;  (3)  slow,  jerky,  scanning  speech ; 
(4)  weakness  of  the  legs,  with  rigidity  of  the  muscles  and 
increased  knee-jerks.  In  addition  there  may  be  vertigo, 
mental  impairment,  optic  atrophy,  incontinence  of  urine,  and 
epileptiform  or  apoplectiform  seizures. 

Paresthesia  is  sometimes  present,  but  anesthesia  is  rare. 
Trophic  disturbances  are  very  uncommon.  The  course 
is  long,  from  2  to  20  years,  and  remissions  not  rarely 
occur. 

Diagnosis. — Paralysis  Agitans. — In  this  disease  the  mask- 
like face,  attitude,  and  gait  are  characteristic.  The  tremor 
decreases  during  effort  and  persists  during  repose  ;  nystag- 
mus and  scanning  speech  are  absent.  Hysteria  may  sim- 
ulate multiple  sclerosis,  but  it  does  not  present  nystagmus, 
optic  atrophy,  or  bladder  disturbances. 

Treatment. — The  general  treatment  is  the  same  as  that 
of  posterior  sclerosis.  Bromids,  hyoscin,  hyoscyamin,  and 
belladonna  have  been  recommended  for  the  tremors. 


HEREDITARY  ATAXIA—SYRINGOMYELIA.  42 1 

HEREDITARY  ATAXIA, 

(Friedreich's  Ataxia.) 

Definition. — A  family  disease,  characterized  anatomically 
by  sclerosis  of  the  lateral  and  posterior  columns  of  the 
spinal  cord,  and  clinically  by  symptoms  resembling  those 
of  locomotor  ataxia. 

etiology. — The  disease  most  frequently  develops  be- 
tween the  second  and  fifteenth  years,  and  usually  attacks  a 
number  of  individuals  in  the  same  family.  Some  cases  can 
be  traced  to  heredity  ;  in  others  no  cause  can  be  ascertained. 

Pathology. — The  chief  lesion  is  a  sclerosis  of  the  lateral 
and  posterior  columns  of  the  spinal  cord. 

Symptoms. — The  characteristic  symptoms  are :  Ataxia 
of  all  purposeful  movements  ;  loss  of  the  knee-jerks  ;  irregu- 
lar jerking  movements  of  the  hands ;  muscular  weakness  ; 
nystagmus ;  a  scanning  speech ;  lateral  spinal  curvature, 
and  deformity  of  the  feet,  generally  talipes  equinus  with  ex- 
tension of  the  big  toe. 

It  differs  from  locomotor  ataxia  in  the  absence  of  sharp 
pains,  of  anesthesia,  of  the  Argyll-Robertson  pupil,  and  in  the 
occurrence  of  nystagmus,  scanning  speech,  and  deformities. 

Prognosis  and  Treatment. — Unfavorable.  The  course 
is  extremely  slow.     Treatment  is  of  no  avail. 

SYRINGOMYELIA* 

Definition. — A  chronic  affection  of  the  spinal  cord,  char- 
acterized anatomically  by  the  formation  of  a  cavity  in  its 
substance,  and  clinically  by  atrophy  of  certain  muscles, 
peculiar  disturbances  of  sensation,  and  various  trophic  dis- 
orders. 

etiology. — It  is  much  more  common  in  males  than  in 
females.  Eighty  per  cent,  of  the  cases  occur  between  the 
ages  of  ten  and  forty  years.  Traumatism  or  one  of  the 
infectious  fevers  may  excite  it. 

Pathology. — The  disease  begins  as  an  overgrowth  of 
the  embryonic  neuroglia.  The  cavity-formation  is  a  second- 
ary process,  and  is  brought  about  by  degeneration  of  the 
gliomatous  tissue,  or  possibly  in  some  instances  by  hemor- 


422  DISEASES   OE  THE   NERVOUS  SYSTEM. 

rhage.  The  cervical  and  upper  dorsal  regions  are  the  usual 
seats  of  the  lesion.  The  cavity  lies  in  the  gray  matter,  and 
may  be  in  the  position  of  the  central  canal  or  somewhat  pos- 
terior to  it.  Secondary  degenerations  are  frequently  ob- 
served in  the  anterior  or  posterior  horns  or  in  the  anterior 
or  posterior  columns. 

Symptoms. — The  disease  usually  attacks  the  upper  ex- 
tremities, the  chief  symptoms  being  wasting  of  the  muscles  ; 
fibrillary  tremors ;  loss  of  painful  and  thermic  sensations, 
while  tactile  sensation  is  preserved  or  but  slightly  affected 
{dissociation  symptom) ;  lateral  spinal  curvature  ;  and  various 
trophic  disturbances,  such  as  arthropathies,  fissures,  ulcers, 
and  gangrene.  Such  eye  symptoms  as  nystagmus,  in- 
equality of  pupils,  and  narrowing  of  the  visual  fields  are 
frequently  observed.  In  many  instances  symptoms  of  lat- 
eral sclerosis,  posterior  sclerosis,  or  bulbar  disease  are  super- 
added. 

The  distinctive  features  of  Morvan's  disease  (probably  a 
form  of  syringomyelia)  are  tactile  anesthesia  and  painless 
felons. 

Diagnosis. — Cervical  pachymeningitis  is  more  painful,  and 
the  anesthesia  includes  tactile  sensation.  In  progressive  mus- 
cular atrophy  and  amyotrophic  lateral  sclerosis  sensory  symp- 
toms are  wanting.  Leprosy  may  be  recognized  by  loss  of 
tactile  sensation,  discoloration  of  skin,  nodular  swellings,  and 
presence  of  baciUi  in  the  secretions  of  the  nose  and  eyes  and 
in  the  serum  of  blisters. 

Prognosis. — Unfavorable.  The  duration  is  from  five  to 
twenty  years. 

Treatment, — This  is  necessarily  symptomatic. 

CAISSON  DISEASE. 

(Divers'  Paralysis.) 

Definition. — A  condition  observed  in  divers  and  others 
subjected  to  increased  atmospheric  pressure,  and  character- 
ized by  motor  and  sensory  paralysis  and  other  nervous 
symptoms. 

Etiology. — A  pressure  of  more  than  two  atmospheres  is 


NEURITIS.  423 

required  to  produce  the  paralysis,  and  the  time  elapsing 
before  its  appearance  lessens  as  the  pressure  increases. 

Pathology. — The  symptoms  have  been  ascribed  by  some 
to  the  liberation  in  the  cord  of  gases  that  have  been  absorbed 
by  the  blood  during  exposure  to  the  high  pressure  ;  by  others, 
to  stasis  of  blood  and  edema.  The  cord  is  found  congested 
and  sometimes  the  seat  of  hemorrhages. 

Symptoms. — The  condition  may  manifest  itself  immedi- 
ately on  reaching  the  surface  or  after  the  lapse  of  several 
hours.  The  most  important  phenomena  are  pains  in  the 
joints,  followed  by  motor  and  sensory  paralysis  in  the  lower 
extremities.  The  bladder  and  rectum  are  sometimes  in- 
volved. Occasionally  the  paralysis  takes  the  form  of  a 
hemiplegia  instead  of  a  paraplegia.  Gastralgia  and  vomiting 
are  common  symptoms.  In  severe  cases  coma  develops  and 
death  follows  in  a  few  hours.  Generally,  however,  the 
symptoms  gradually  subside,  and  the  power  is  fully  restored 
in  the  course  of  a  few  days  or  a  few  weeks. 

Treatment. — As  a  preventive  measure,  the  transition 
from  high  to  low  pressure  should  be  accomplished  grad- 
ually.    Marked  cases  should  be  treated  as  acute  myelitis. 


DISEASES   OF  THE   NERVES. 

NEURITIS* 

Definition. — Inflammation  of  nerves. 

^Etiology. — (i)  It  may  result  from  traumatism — blows, 
wounds,  or  compression.  (2)  It  may  be  due  to  exposure  to 
cold  and  wet.  (3)  It  may  be  secondary  to  inflammation  of 
adjacent  structures.  (4)  It  may  be  secondary  to  rheumatism, 
gout,  syphilis,  or  one  of  the  infectious  fevers. 

Pathology. — The  sheath,  interstitial  connective  tissue,  or 
fibers  may  be  independently  affected,  but,  as  a  rule,  all  parts 
of  the  nerve  are  involved.  When  the  process  is  acute,  the 
nerve  is  red  and  swollen,  and  microscopic  examination  re- 
veals an  infiltration  of  leukocytes,  with  more  or  less  granular 
degeneration  of  the  fibers. 

In  chrofiic  neuritis  the  nerve-trunk  is  gray,  shriveled^  and 


424  DISEASES   OE   THE   NERVOUS  SYSTEM. 

hard,  and  microscopic  examination  shows  an  overgrowth  of 
connective  tissue  and  granular  degeneration  of  fibers. 

Symptoms  of  Acute  Neuritis. — There  are  three  sets 
of  phenomena — sensory,  motor,  and  trophic. 

Sensory  Symptoms. — There  is  severe  pain  following  the 
course  of  the  affected  nerve,  which  is  tender  to  the  touch. 
The  pain  is  often  associated  with,  various  manifestations  of 
paresthesia,  such  as  burning,  numbness,  tingHng,  and  the 
like.  The  part  is  at  first  hyperesthetic,  but  later  it  is  more 
or  less  anesthetic. 

Motor  Symptoms. — Muscular  power  is  impaired ;  there 
may  be  fibrillar  tremors ;  the  reflexes  are  diminished  or  lost. 

Trophic  Symptoms.— Kn  eruption  of  herpes  sometimes  fol- 
lows the  affected  nerves.  The  skin  may  become  glossy  and 
the  nails  lusterless  and  brittle.  In  advanced  cases  there  are 
wasting  of  muscles  and  impaired  electrocontractility.  Occa- 
sionally effusion  into  the  joints  is  observed. 

In  severe  cases  there  may  be  febrile  symptoms. 

Chronic  neuritis  is  characterized  by  pain,  anesthesia, 
paresis,  atrophy  and  contracture  of  the  muscles,  reactions 
of  degeneration,  "  glossy  skin,"  and  thickening  and  brittle- 
ness  of  the  nails. 

Diagnosis. — Neuritis  may  be  mistaken  for  neuralgia; 
but  in  the  latter  the  pain  is  paroxysmal  and  is  unassociated 
with  tenderness  along  the  course  of  the  nerve,  paresthesia, 
anesthesia,  paresis,  and  changes  in  the  electrocontractility. 

Prognosis. — In  acute  cases  the  prognosis  is  guardedly 
favorable ;  the  duration  is  from  a  few  days  to  several  weeks. 
In  chronic  neuritis,  after  the  development  of  marked  trophic 
changes,  the  prognosis  is  grave. 

Treatment. — The  cause  should  be  ascertained,  and,  if 
possible,  removed.  In  rheumatism,  alkalis  and  salicylates 
are  indicated.  In  syphilis,  iodid  of  potassium  should  be 
administered  in  large  doses.  The  part  should  be  put  at  rest. 
For  the  pain,  sedative  lotions  (lead-water  and  laudanum), 
warm  fomentations,  or  small  blisters  may  be  applied  to  the 
affected  parts,  and  morphin  administered  hypodermically. 
When  morphin  is  contraindicated,  salicylic  compounds  or 
phenacetin  may  be  employed  in  its  stead.  Such  a  combina- 
tion as  the  following  is  often  efficacious : 


MULTIPLE   NEURITIS.  425 

R  .     Acetanilidi ^j 

Salopheu ^iss 

Codeinas  sulphatis       gr.  ij. — M. 

Fiant  charlulas  No.  xij. 

SiG. — One  every  three  or  four  hours. 

After  the  acute  symptoms  have  subsided  massage  and  elec- 
tricity should  be  resorted  to,  in  order  to  restore  the  func- 
tions of  the  nerve. 

MULTIPLE  NEURITIS* 

Definition.— Inflammation  of  several  nerve-trunks  re- 
sulting from  a  general  cause,  and  characterized  by  pain, 
paresthesia,  anesthesia,  paresis,  and  muscular  atrophy. 

etiology. — The  disease  may  result  from  (i)  exposure 
to  cold  and  wet ;  (2)  specific  infections,  such  as  diphtheria, 
influenza,  measles,  rheumatism,  etc. ;  (3)  certain  poisons  de- 
rived from  without,  such  as  alcohol,  lead,  arsenic,  carbon 
monoxid,  sulphonal,  etc. ;  (4)  certain  auto-intoxications,  such 
as  occur  in  gout  and  diabetes  ;  (5)  malnutrition,  as  in  ad- 
vanced arteriosclerosis.  In  the  Orient  multiple  neuritis  oc- 
curs as  an  endemic  disease  (beri-beri  or  kakke)  which  is  prob- 
ably of  microbic  origin. 

Symptoms. — The  acute  form  is  characterized  by  chilli- 
ness, moderate  fever  (102  °-i03  °  F.),  pains  in  the  head  and 
back,  anorexia,  constipation,  and  the  following  local  phe- 
nomena :  pain,  numbness,  and  tingling  in  the  affected  limbs, 
loss  of  power,  especially  in  the  legs  and  extensor  muscles 
of  the  wrist,  tenderness  over  the  nerve-trunks,  abolition  of 
reflexes,  and  more  or  less  anesthesia. 

Death  may  occur  within  one  or  two  weeks  from  cardiac 
or  respiratory  paralysis.  Generally,  however,  recovery  fol- 
lows in  from  a  few  weeks  to  several  months. 

Chronic  Form. — Sensory  symptoms  are  prominent.  Numb- 
ness, tingling,  hyperesthesia,  and  intermittent  pains  appear 
early  and  are  followed  by  some  anesthesia,  especially  of  the 
legs  and  hands.     The  nerve-trunks  are  sensitive. 

Motor  Symptoms. — Weakness  of  the  legs  and  forearms 
develops  rapidly.  The  typical  paresis  is  foot-drop  and  wrist- 
drop. The  sphincters  are  not  affected.  The  knee-jerks  are 
lost.     As  a  rule  the  paralyzed  muscles  do  not  respond  to 


426  DISEASES   OF   THE   NERVOUS  SYSTEM. 

the  faradic  current,  but  yield  the  reaction  of  degeneration 
with  the  galvanic  current.  If  the  patient  is  able  to  walk,  his 
gait  is  characteristic.  To  avoid  dragging  his  toes,  he  raises 
the  foot  high,  throws  it  suddenly  forward,  and  brings  it  down 
flat  on  the  floor,  as  if  walking  over  obstacles  (steppage  gait). 

Vasomotor  and  Trophic  Disturbaiices. — The  paralyzed 
muscles  are  flabby  and  soon  waste.  Edema  of  the  feet  and 
hands,  and  local  sweating  are  often  seen.  Changes  in  the 
nails  are  common.     Bedsores  do  not  appear. 

Mental  Syniptojns. — Delirium  with  hallucinations  and 
illusions  are  frequently  observed  in  the  alcoholic  type. 

Diagnosis.^ — Locomotor  Ataxia. — The  absence  of  the 
lightning-pains,  girdle  sensation,  Argyll- Robertson  pupil,  and 
the  presence  of  paralysis,  wasting,  and  neural  tenderness  will 
serv^e  to  distinguish  multiple  neuritis  from  locomotor  ataxia. 

Prognosis. — Recovery  usually  occurs  in  time,  when  the 
cause  can  be  removed. 

Treatment. — This  is  the  same  as  for  localized  neuritis. 

SQATICA* 

Definition. — Pain  along  the  sciatic  nerve,  usually  result- 
ing from  neuritis. 

]^tiolog"y. — It  is  usually  primary,  developing  in  rheu- 
matic or  gouty  persons  after  exposure  to  cold  and  wet. 
Some  cases  owe  their  origin  to  syphilis.  Occasionally  it  is  a 
secondary  condition  resulting  from  the  presence  of  an  intra- 
pelvic  growth  or  from  caries  of  the  bone  in  hip-joint  disease. 

Symptoms. — The  disease  may  begin  abruptly  or  gradu- 
ally, and  is  characterized  by  a  sharp  shooting  pain  running 
down  the  back  of  the  thigh.  Movement  of  the  limb  intensi- 
fies the  suflering.  The  pain  may  be  uniformly  distributed 
along  the  course  of  the  nerve,  but  not  infrequently  there  are 
certain  spots  where  it  is  more  intense.  Subjective  sensa- 
tions, such  as  tingling  and  numbness,  are  often  noted.  The 
nerve  may  be  extremely  sensitive  to  touch.  The  symptoms 
grow  worse  at  night  and  on  the  approach  of  stormy  weather. 
The  duration  of  the  attack  varies  from  a  few  days  to  several 
months.  In  long-standing  cases  the  muscles  become 
atrophied  and  rigido 


FACIAL   PARALYSIS.  427 

Diagnosis. — Coxalgia. — In  this  affection  the  pain  is 
most  marked  in  the  hip-  and  knee-joints  ;  pressure  over  the 
trochanter  eHcits  pain  ;  and  the  nerve  is  not  tender  to  the 
touch. 

Prognosis. — Recovery  follows  in  the  majority  of  cases 
when  treatment  is  instituted  early  and  is  persistently  carried 
out.  In  some  cases  relapses  occur  frequently,  and  finally 
the  pain  becomes  more  or  less  continuous. 

Tlreatment. — The  first  indication  is  to  remove  the  cause. 
In  acute  cases  rest  in  bed  is  essential.  In  severe  cases  the 
limb  should  be  immobilized  by  means  of  salt  bags  or  a  long 
straight  splint.  Free  evacuation  of  the  bowels  should  be 
secured  in  order  to  deplete  the  pelvic  veins.  When  there  is 
a  history  of  rheumatism  or  the  attack  has  been  induced  by 
cold,  salicylates  should  be  given  in  full  doses.  When  there 
is  reason  to  suspect  syphilis,  iodids  should  be  given  a  fair 
trial.  Irrespective  of  the  cause,  phenacetin  or  antipyrin  may 
be  useful  in  relieving  pain.  Counterirritation  often  affords 
much  relief  When  the  pain  is  very  severe,  this  is  best 
accomplished  by  means  of  small  blisters  or  Hght  touches  of 
the  actual  cautery  applied  over  the  points  of  greatest  ten- 
derness. In  some  cases  acupuncture  acts  very  satisfactorily. 
In  milder  cases  the  Scottish  douche — in  which  a  stream  of 
warm  water  of  gradually  increasing  temperature  is  directed 
on  the  course  of  the  nerve  until  the  pain  subsides,  when  it 
is  suddenly  changed  for  a  cold  jet — is  an  efficient  remedy. 
Agonizing  pain  must  be  relieved  by  injections  of  cocain  (^ 
grain),  chloroform  (5  to  10  minims),  guaiacol  (2  to  3  minims), 
or  morphin  (  ^  to  J  grain),  made  deeply  and  as  near  to  the 
nerve  as  possible.  Morphin  should  be  withheld  as  long  as 
possible.  In  some  cases  deep  injections  of  distilled  water 
act  remarkably  well.  Massage  is  indicated  only  when  the 
acute  symptoms  have  subsided,  and  should  then  not  be  too 
energetic. 

FACIAL  PARALYSIS, 

(Bell's  Palsy.) 

etiology. — Paralysis  of  one  side  of  the  face  may  result: 
(l)  From  a  tumor,  clot,  or  abscess  involving  the  facial  center 


428  DISEASES   OF  THE  NERVOUS  SYSTEM. 

on  the  cortex  of  the  brain  or  the  nucleus  of  the  facial  nerve ; 
{2)  from  the  pressure  of  inflammatory  exudate  on  the  nerve- 
trunk  between  the  brain  and  the  skull ;  (3)  from  paralysis 
of  the  nerve  within  the  petrous  portion  of  the  temporal 
bone,  excited  by  a  fracture  or  by  an  extension  of  inflamma- 
tion of  the  middle  ear ;  (4)  from  inflammation  of  the  periph- 
eral filaments,  excited  by  exposure,  injury,  rheumatism,  or 
one  of  the  infectious  fevers. 

Symptoms. — The  side  affected  is  expressionless ;  the 
natural  hnes  are  obliterated;  the  angle  of  the  mouth  droops; 
the  eye  cannot  be  closed ;  tears  flow  over  the  cheek ;  and 
speech  is  affected  from  an  inability  to  pronounce  the  labials. 
When  the  patient  attempts  to  laugh  or  whistle,  the  absence 
of  movement  on  the  affected  side  becomes  still  more  con- 
spicuous. In  peripheral  neuritis  the  reflexes  are  abolished ; 
and  when  the  nerve  is  involved  in  the  temporal  bone,  there 
may  be  a  loss  of  taste  in  the  anterior  part  of  the  tongue. 

Diagnosis. — When  the  lesion  is  supranuclear  the  upper 
muscles  of  the  face  (orbicularis  palpebrarum  and  frontalis) 
usually  escape,  voluntary  movements  are  more  impaired 
than  emotional  movements,  electric  reactions  are  normal, 
and  there  is  generally  hemiplegia. 

When  the  lesion  is  nuclear  or  infranuclear  all  the  muscles 
of  one  side  of  the  face,  including  those  of  the  forehead  and 
eye,  are  involved,  both  emotional  and  voluntary  movements 
are  lost,  and  the  electric  reactions  are  altered  in  character. 
In  nuclear  lesions  other  cranial  nerves  are  usually  involved 
with  the  facial.  In  pontine  lesions  there  is  often  paralysis 
of  the  limbs  on  the  side  opposite  to  the  facial  palsy  (crossed 
paralysis).  When  the  nerve  is  involved  within  the  Fallopian 
canal  there  is  frequently  loss  of  taste  in  the  anterior  part  of 
the  tongue  on  the  paralyzed  side. 

Prognosis. — The  prognosis  will  vary  with  the  cause.  It 
should  be  guardedly  favorable  when  the  paralysis  is  due  to 
peripheral  neuritis. 

Treatment. — The  cause  should  be  ascertained,  and,  if 
possible,  removed.  In  paralysis  of  centric  origin  little  can 
be  done  except  in  syphilitic  cases.  In  middle-ear  disease 
remedies  should  be  directed  to  that  origin.     When  paralysis 


HEADACHE. 


429 


results  from  inflammation  of  the  peripheral  filaments  of  the 
facial  nerve,  blisters  should  be  applied  near  the  stylomastoid 
foramen.  Later,  a  course  of  iodid  of  potassium  will  be  use- 
ful, and  restoration  of  power  may  be  materially  assisted  by 
massage  and  electricity. 


FUNCTIONAL   NERVOUS   DISEASES. 

HEADACHE. 

(Cephalalgia.) 

Headache  of  Organic  Brain  Disease. — This  form  is  observed 
in  meningitis,  cerebral  tumor,  abscess,  softening,  etc.,  and 
may  be  recognized  by  its  persistence  and  by  the  associated 
evidences  of  organic  cerebral  disease,  such  as  optic  neuritis, 
mental  aberration,  paralysis,  especially  of  the  facial  muscles, 
and  vomiting  arising  independently  of  other  gastric  symp- 
toms. 

Under  this  head  is  included  the  headache  of  syphilis, 
which  may  be  diagnosed  by  the  history ;  by  the  other  evi- 
dences of  syphilis ;  by  its  frequent  association  with  som- 
nolence ;  and  by  the  effect  of  iodid  of  potassium. 

Headache  of  Cerebral  Hyperemia. — Active  cerebral  conges- 
tion  usually  results  from  prolonged  mental  work,  fever,  or 
exposure  to  the  sun.  Toxic  and  reflex  headaches  are  often 
directly  due  to  active  cerebral  congestion,  but  these  will  be 
discussed  later. 

Passive  cerebral  congestion  may  result  from  obstruction  to 
the  return  of  blood  from  the  brain,  as  by  a  tumor  of  the 
neck  or  cardiac  disease.  It  is  also  common  in  elderly  people 
from  a  relaxed  condition  of  the  vessels. 

In  cerebral  congestion  the  headache  is  of  a  throbbing  or 
bursting  character  ;  the  head  is  hot ;  the  face  flushed ;  the 
eye-ground  injected ;  and  the  distress  is  increased  by  lower- 
ing the  head. 

The  exciting  cause  must  be  determined  by  the  history  and 


430  DISEASES   OF   THE  NERVOUS  SYSTEM. 

by  a  careful  examination  of  the  various  organs,  especially 
the  heart. 

Headache  of  Cerebral  Anemia. — This  is  frequently  depen- 
dent upon  general  anemia.  It  is  also  common  in  neuras- 
thenia resulting  from  overwork,  prolonged  emotional  excite- 
ment, excesses,  etc.  More  rarely  it  is  dependent  upon  aortic 
stenosis. 

In  cerebral  anemia  the  pain  is  frequently  vertical ;  it  is  not 
throbbing,  but  it  is  described  as  a  sensation  of  weight  or 
gnawing;  the  extremities  are  cold;  the  face  and  eye-grounds 
are  pale ;  the  mind  is  depressed ;  fainting  spells  are  often 
present ;  lowering  the  head  and  the  inhalation  of  nitrite  of 
amyl  relieve  the  pain. 

Reflex  Headache. — Headache  is  often  due  to  eye-strain  re- 
sulting from  refraction  errors,  and  in  obstinate  cases  a  careful 
examination  of  the  eyes  should  always  be  made.  Headache 
of  this  origin  is  frequently  a  browache,  and  may  be  asso- 
ciated with  restlessness,  vomiting,  and  insomnia.  It  is  in- 
duced or  aggravated  by  prolonged  use  of  the  eyes. 

Ovarian  or  uterine  diseases  often  produce  a  reflex  head- 
ache. It  is  usually  located  at  the  vertex,  and  is  relieved  by 
pressure  of  the  hand. 

Gastric  irritation  is  responsible  for  many  headaches ;  the 
latter  are  invariably  relieved  by  vomiting,  and  are  usually 
associated  with  other  evidences  of  stomachic  disorder. 

Nasal  catarrh  may  induce  persistent  headache,  which  is 
generally  confined  to  the  forehead,  temples,  or  vertex,  and 
is  aggravated  by  exacerbations  of  the  catarrh.  The  pain  is 
often  associated  with  tenderness  of  the  inner  wall  of  the 
orbit,  and  is  increased  by  irritating  the  nasal  mucous  mem- 
brane with  a  probe. 

Toxemic  Headache. — A  persistent  headache  often  results 
from  Bright's  disease,  and  is  uremic  in  origin.  It  may  be 
recognized  by  the  high  arterial  tension  and  by  the  albumin 
and  casts  in  the  urine.  A  urinary  analysis  should  be  made 
in  all  cases  of  persistent  headache. 

Gout  produces  an  intractable  headache  that  is  associated 
with  vertigo,  great  irritability  of  temper,  and  a  "  brick-dust " 
deposit  in  the  urine. 


HEADACHE.  43 1 

Chronic  malarial  poisoning  may  manifest  itself  in  a  head- 
ache which  is  usually  confined  to  the  supra-orbital  region. 
It  is  apt  to  recur  at  regular  intervals,  is  often  associated  with 
tenderness  over  the  supra-orbital  nerve,  and  is  relieved  only 
by  large  doses  of  quinin. 

A  headache  of  rheiiviatic  origin  sometimes  develops  in 
those  subject  to  rheumatism.  It  is  frequently  excited  by 
exposure  or  a  sudden  change  of  temperature.  It  usually 
affects  the  aponeurosis  of  the  occipitofrontalis  and  temporal 
muscles,  is  increased  by  wrinkHng  the  forehead  and  forcibly 
moving  the  jaws,  and  is  associated  with  tenderness  of  the 
scalp. 

Alcoholism  is  often  associated  with  headache.  In  acute 
alcoholism  the  headache  probably  results  from  cerebral 
hyperemia ;  in  chronic  alcoholism  it  is  often  due  to  a  low 
grade  of  meningitis. 

Among  other  headaches  of  toxic  origin  may  be  mentioned 
those  due  to  constipation,  lead-poisoning,  diabetes,  infectious 
fevers,  and  absorption  of  foul  gases. 

Hysteric  Headache. — In  hysteria  there  is  often  a  persistent 
headache,  which  grows  worse  at  the  menstrual  periods,  and 
which  improves  under  pleasurable  excitement.  It  may  be 
diffuse,  but  frequently  it  is  localized,  and  is  described  as  re- 
sembling the  effect  that  would  be  produced  by  a  nail  being 
driven  into  the  head ;  hence  it  has  been  termed  claims. 

Diagnosis. — Headache  must  be  distinguished  from  mi- 
graine. In  the  latter  the  attacks  are  usually  more  distinctly 
periodic ;  the  pain  is  often  unilateral,  and  is  frequently  ac- 
companied by  vomiting,  vasomotor  disturbances,  and  sub- 
jective visual  phenomena. 

Headache  in  the  region  of  the  orbit  may  be  mistaken  for 
actite  glaucoma^  but  in  the  latter  condition  the  eye  is  in- 
flamed ;  the  cornea  is  hazy;  the  pupil  is  sluggish  ;  vision  is 
impaired ;  and  on  palpation  the  affected  eyeball  is  found  to 
be  harder  than  its  fellow. 

Treatment. — In  the  interval  between  the  attacks  care- 
ful search  should  be  made  for  the  cause,  which,  if  pos.r- 
ble,  must  be  removed.  In  the  reflex  headache  of  eye-straii. 
the  adjustment  of  proper  glasses  is  often  all  that  is  required. 


432  DISEASES   OE  THE  NERVOUS  SYSTEM. 

In  the  headache  of  gastric  origin  appropriate  remedies 
should  be  directed  to  the  stomach.  In  the  headache  of 
anemia  a  nutritious  diet,  with  iron,  arsenic,  and  other  tonics, 
will  be  required.  In  headaches  of  uremic  origin  a  milk  diet 
with  measures  calculated  to  increase  the  action  of  the  skin, 
bowels,  and  kidneys  will  often  afford  considerable  relief. 
In  malarial  headache  quinin  in  large  doses  with  arsenic  will 
effect  a  cure. 

The  Attack. — In  headache  dependent  upon  gastric  acidity, 
after  unloading  the  stomach  with  a  non-irritating  emetic, 
bromid  with  antacids  will  prove  useful,  thus : 

R.     Sodii  bromidi ^ij 

Spiritus  ammonise  aromatici f^ij 

Aquse q.  s.  ad  f^iij. — M. 

SiG. — A  tablespoonful  every  hour  or  two. 

In  headache  of  acute  cerebral  congestion  the  feet  should 
be  soaked  for  ten  or  fifteen  minutes  in  very  hot  water ;  an . 
ice-bag  placed  on  the  head ;  and  some  sedative  like  the  fol- 
lowing administered  : 

R  •     Acetphenetidini ^^j 

Sodii  bromidi ^^ss-. — M. 

Fiant  chartulge  No.  xij. 

SiG. — One  powder  every  hour  or  two  until  relieved. 

When  the  attack  is  very  severe,  aconite  (i  or  2  drops) 
may  be  given  every  hour  or  two. 

In  cerebral  anemia  relief  temporarily  follows  the  use 
of  antipyrin  or  phenacetin,  especially  in  combination  with 
cafifein,  thus  : 

R .     Acetphenetidini ^^iss 

Caffeinae  citratse gr.  xxiv. — M. 

Fiant  chartulse  No.  xij. 
SiG. — One  as  required. 

In  rheumatic  headache  salicylic  compounds  are  very 
useful ;  they  may  be  combined  with  phenacetin  or  antipyrin  : 

R .     Acetphenetidini 

Salophen aa  ^iss. — M. 

Fiant  chartulge  No.  xij. 

SiG. — One  every  two  or  three  hours. 

In  uremic  headache  the  diet  should  be  restricted  to  milk, 
action  of  the  bowels  secured  by  a  saline  draft,  and  diuresis 


VERTIGO.  433 

encouraged  by  digitalis,  caffein,  or  the  vegetable  salts  of 
potassium  : 

R .     Potassii  citratis ^ij 

Spiritus  juniperi f^vj 

Spiritus  cetheris  nitrosi f:^ij 

Infusi  scoparii f^vj.— M. 

SiG. — A  wineglassful  thrice  daily.  (Day.) 

VERTIGO. 

(Dizziness ;  Giddiness ;  Swimming  in  the  Head.) 

Definition. — A  sense  of  unstable  equilibrium  in  which 
the  patient  himself  or  surrounding  objects  appear  to  be  in  a 
state  of  rapid  oscillation  or  rotation.  It  is  a  symptom  of 
many  conditions. 

^tiologfy. — Vertigo  may  result  from  : 

1.  Cerebral  anemia  or  congestion.  The  dizziness  pre- 
ceding a  fainting  fit  is  an  illustration  of  the  former,  and  that 
following  exposure  to  the  rays  of  the  sun  is  an  illustration 
of  the  latter.  Vertigo  is  often  a  pronounced  symptom  of 
chronic  heart  disease  and  of  arteriosclerosis  is  included  under 
this  head. 

2.  Diseases  of  the  ear.  Vertigo  may  occur  in  any  affec- 
tion of  the  ear,  but  it  is  especially  severe  in  the  symptom- 
complex  known  as  Meniere's  disease  (see  p.  434). 

3.  Palsy  of  the  ocular  muscles.  This  form  of  vertigo  is 
often  associated  with  nystagmus  and  is  relieved  by  closing 
the  eyes. 

4.  Reflex  irritation.  The  most  common  example  of  this 
form  is  the  vertigo  dependent  upon  gastric  disturbances. 
It  is  also  noted  in  some  cases  of  nasal  obstruction  and  ovar- 
ian disease. 

5.  Organic  disease  of  the  brain  and  cord.  Cerebral  tumor, 
meningitis,  and  softening  -are  frequently  associated  with  ver- 
tigo. It  is  often  quite  marked  in  cerebellar  disease.  It  may 
be  a  pronounced  symptom  in  disseminated  sclerosis  and 
locomotor  ataxia. 

6.  Toxic  substances  in  the  blood.  The  vertigo  observed 
in  gout,  uremia,  and  diabetes  is  included  under  this  head. 

28 


434  DISEASES   OF   THE   NERVOUS  SYSTEM. 

When  taken  in  large  doses,  certain  drugs,  as  alcohol,  bella- 
donna, cannabis  indica,  lobelia,  and  conium,  may  produce 
the  symptom.  It  is  often  a  marked  symptom  of  chronic 
lead-poisoning. 

7.  Epilepsy.  Vertigo  may  precede,  follow,  or  take  the 
place  of  an  epileptic  seizure. 

8.  Psychic  disturbances.  Vertigo  is  not  uncommon  in 
hysteria,  neurasthenia,  and  the  traumatic  neuroses. 

9.  Unknown  causes.  The  term  essential  vertigo  has  been 
applied  to  those  cases  in  which,  after  the  most  exhaustive 
study,  no  adequate  cause  can  be  ascertained.  There  is 
sometimes  a  hereditary  tendency  to  this  form  of  vertigo. 

Diagnosis. — Vertigo  must  be  distinguished  from  petit 
mal,  or  minor  epilepsy.  The  history,  the  presence  of  a  defi- 
nite cause,  and  the  absence  of  unconsciousness  and  of  con- 
vulsive movements  will  serve  to  separate  vertigo  from 
epilepsy. 

The  determination  of  the  cause  of  the  vertigo  must  be 
based  upon  the  history,  the  age  at  which  it  develops,  and  a 
critical  examination  of  the  various  organs. 

Prognosis. — This  will  depend  entirely  on  the  cause ; 
when  the  latter  can  be  removed,  the  prognosis  is  favorable. 

Treatment. — This  must  be  directed  to  the  causal  con- 
dition. 

MENIERE'S  DISEASE. 

(Labyrinthine  Vertigo ;  Aural  Vertigo.) 

Definition. — Paroxysmal  vertigo,  probably  depending 
upon  disease  of  the  internal  ear. 

Btiology  and  Pathology.  —  The  exact  cause  of 
Meniere's  disease  is  still  undetermined.  In  some  cases,  how- 
ever, inflammatory  changes  have  been  observed  in  the  semi- 
circular canals.  Very  severe  acute  attacks  are  sometimes 
observed  in  patients  previously  healthy.  In  these  the  lesions 
are  probably  an  active  hyperemia  of,  or  a  hemorrhage  into, 
the  labyrinth.  It  is  probable  that  mild  forms  of  the  disease 
can  be  indirectly  induced  by  lesions  of  the  middle  ear. 

Symptoms. — Frequently  prodromes  precede  the  attack, 
such  as  deafness  or  earache.  These,  however,  may  be  ab- 
sent, and  the  attacks  ushered  in  with  extreme  vertigo  and 


EPILEPSY.  435 

tinnitus  aurium.  The  latter  is  often  compared  to  the  escape 
of  steam,  the  buzz  of  an  insect,  or  the  discharge  of  a  cannon. 
The  patient  feels  as  if  he  or  surrounding  objects  were  being 
whirled  violently  around,  and  in  severe  cases  the  face  is 
pale  and  anxious ;  the  surface  is  clammy ;  there  are  nausea 
and  vomiting  ;  and  the  patient  falls  unconscious. 

As  a  rule,  there  is  deafness  in  one  ear  at  least,  but  excep- 
tionally hearing  may  be  quite  normal.  At  first  the  parox- 
ysms may  occur  at  long  intervals,  but  as  the  disease  ad- 
vances they  become  more  frequent  and  the  tinnitus  and 
deafness  become  more  marked. 

Diagnosis.' — The  paroxysmal  vertigo,  deafness,  and  tin- 
nitus aurium  are  the  diagnostic  features. 

Prognosis. — The  prognosis  should  always  be  guarded. 
Some  cases  recover  entirely,  but  in  the  majority  the  vertigi- 
nous attacks  continue  until  the  deafness  in  the  affected  ear 
becomes  complete. 

Treatment. — The  middle  ear  should  be  carefully  ex- 
amined, and  any  existing  disease  treated.  Severe  counter- 
irritation  by  blisters  or  the  actual  cautery  applied  behind  the 
ear  may  be  of  some  service.  Bromid  of  potassium,  hydro- 
bromic  acid,  cimicifuga,  or  gelsemium  in  full  doses  some- 
times afford  temporary  rehef  Daily  injections  of  pilocarpin 
(i  g^^^^)»  ^s  originally  recommended  by  Politzer,  are  occa- 
sionally of  service. 

EPILEPSY. 

(Idiopathic  Epilepsy;  Falling  Sickness.) 

Definition.-^ A  chronic  disease  of  the  nervous  system, 
characterized  by  periodic  atacks  of  unconsciousness,  which 
may  or  may  not  be  associated  with  convulsive  seizures. 

Ktiologfy. — Heredity  predisposes,  and  the  ancestral  dis- 
ease may  not  have  been  epilepsy,  but  insanity,  hysteria, 
or  another  neurosis.  It  generally  begins  before  puberty, 
and  very  rarely  after  the  twenty-fifth  year.  All  causes  that 
impair  the  health  and  exhaust  the  nervous  system  exert  a 
predisposing  influence.  The  reflex  convulsions  of  children 
resulting  from  gastric  irritation,  worms,  etc.,  if  long  contin- 
ued, may  induce  chronic  epilepsy.     In  these  cases,  although 


436  DISEASES   OF   THE   NERVOUS  SYSTEM. 

the  exciting  cause  has  been  removed,  the  habit  of  sponta- 
neous motor  discharge,  through  constant  repetition,  is  estab- 
hshed,  and  may  continue  through  hfe.  In  those  subject  to 
convulsions,  overwork,  gastric  irritation,  or  excitement  may 
precipitate  an  attack. 

Pathology. — No  demonstrable  causal  lesions  are  de- 
tected. The  disease  apparently  depends  upon  an  instability 
of  the  motor  centers,  so  that  from  trivial  exciting  causes 
violent  discharges  occur  from  time  to  time. 

Symptoms. — Grand  MaL — The  seizure  is  often  preceded 
by  a  peculiar  sensation  termed  an  aura,  beginning  in  a  finger 
or  toe,  and  rising  until  it  involves  the  head,  when  the 
patient  gives  a  shrill  scream  and  falls  to  the  floor  uncon- 
scious. At  first  the  face  is  pale,  the  pupils  contracted,  and 
the  body  thrown  into  a  tonic  spasm  in  which  the  head  is 
retracted  and  rotated,  the  Hmbs  forcibly  extended,  and  the 
thumbs  turned  into  the  palms  and  firmly  clenched  by  the 
flexed  fingers.  In  a  few  seconds  the  tonic  spasm  relaxes, 
the  movements  become  clonic  or  intermittent,  the  pupils 
dilated,  and  the  face  cyanosed.  From  the  violent  contrac- 
tion of  the  masseters  frothy  saliva,  often  blood-streaked, 
pours  from  the  mouth.  The  clonic  spasms  continue  for  a 
minute  or  two,  and  are  generally  followed  by  a  period  of 
coma  lasting  from  a  few  minutes  to  several  hours.  Some- 
times the  patient  returns  at  once  to  consciousness,  and 
complains  simply  of  weakness,  muscular  soreness,  and  men- 
tal confusion.  More  rarely  the  convulsion  is  followed  by 
an  outbreak  of  mania  or  of  epileptic  automatism,  a  condition 
in  which  the  patient  unconsciously  performs  simple  or  com- 
plicated acts. 

Petit  Mai. — In  this  type  the  seizure  consists  of  momentary 
unconsciousness,  with  pallor,  and  rarely  twitching  of  the 
muscles.  The  patient  suddenly  stops  in  the  midst  of  his 
work  or  conversation,  remains  quiet  for  a  few  seconds,  and 
then  continues  where  he  left  off,  perhaps  unconscious  of  * 
the  interruption.  Petit  inal  may  be  a  forerunner  of  grand 
nial  or  may  alternate  with  it. 

Between  these  two  extremes  the  seizures  manifest  all 
grades  of  severity.  The  frequency  of  the  paroxysms  varies 
considerably :  they  may  occur  as  seldom  as  once  a  year  or 


EPILEPSY.  437 

as  often  as  ten  or  twelve  times  a  day.  A  marked  periodicity 
in  their  recurrence  is  often  observed. 

The  term  ''  status  epilepticus  "  is  appHed  to  a  condition  in 
which  the  convulsions  follow  each  other  in  rapid  succession 
without  a  return  of  consciousness. 

The  epileptic  may  manifest  no  other  symptoms  beyond 
the  convulsions,  but  when  the  latter  are  very  frequent,  the 
health  fails  and  the  mental  power  deteriorates. 

Diagnosis. — The  convulsions  of  chronic  organic  disease 
of  the  brain  may  be  mistaken  for  those  of  idiopathic  epilepsy, 
but  the  former  do  not  often  develop  before  the  age  of  twenty- 
five  ;  they  are  frequently  confined  to  one  member  or  begin 
in  one  member  and  then  become  general  (Jacksonian  epi- 
lepsy) ;  and  they  may  be  associated  with  a  history  or  the 
concomitant  symptoms  of  syphilis,  or  with  evidences  of 
local  injury. 

Uremia. — Uremic  convulsions  may  be  recognized  by  the 
history  and  the  results  of  the  urinary  analysis. 

Prognosis. —  Generally  unfavorable.  Arrest  of  the 
disease  is  rare,  but  amelioration  is  often  secured  by  treat- 
ment. 

Treatment. — Hygienic  treatment  is  of  the  utmost  im- 
portance. Moderate  exercise,  both  mental  and  physical,  is 
beneficial.  Idleness  and  seclusion  have  a  baneful  effect. 
Home  training  must  be  carried  on  with  the  greatest  care, 
much  tact  and  firmness  being  required  to  prevent  loss  of 
self-control.  Children  who  are  particularly  irascible  are 
often  much  better  trained  in  a  special  institution.  As  a  rule, 
a  diet  that  is  for  the  most  part  vegetable  will  be  found  to 
be  best  adapted  to  the  patient's  condition,  but  when  the 
disease  is  associated  with  lowered  vitality,  a  fair  amount  of 
animal  food  should  be  permitted.  Overloading  the  stomach 
is  a  potent  factor  in  precipitating  attacks.  The  bowels  must 
be  regulated  by  diet,  and,  if  necessary,  by  mild  aperients. 
Liberal  water-drinking,  frequent  bathing,  followed  by  fric- 
tion of  the  skin,  light  exercise  in  the  open  air,  and  other 
measures  that  favor  elimination  are  to  be  recommended. 
General  tonics,  like  iron,  arsenic,  and  cod-liver  oil,  are  some- 
times required  to  combat  anemia  and  malnutrition. 


438 


DISEASES   OE  THE  NERVOUS  SYSTEM. 


Although  very  few  cases  of  epilepsy  are  purely  reflex, 
local  irritation — phimosis,  adherent  prepuce,  worms,  a  for- 
eign body  in  the  nose  or  ear,  and  painful  cicatrices — should 
be  carefully  sought  for  and,  if  found,  removed. 

The  most  reliable  drugs  are  the  bromids :  one  or  two 
drams  of  a  combination  of  the  bromids  of  sodium,  potas- 
sium, and  ammonium  may  be  given  daily.  Strontium  bro- 
mid  is  often  efficacious,  and  it  is  less  depressing  than  the 
other  bromids.  The  tendency  to  acne  may  be  considerably 
lessened  by  the  addition  of  a  drop  or  two  of  Fowler's  solu- 
tion with  each  dose.  A  small  amount  of  antipyrin  often 
lessens  the  amount  of  the  bromid  required  to  check  the 
convulsions. 

R.    Potassii  bromidi 

Ammonii  bromidi aa   ^iij 

Liquoris  potassii  arsenitis  .    .     .    .    .    .  f^j 

Antipyrinse .^j 

Aquae  menthse  piperitce      .    .     q.  s.  ad  f^vj. — M. 

SiG. — A  tablespoonful  in  water  night  and  morning. 

In  nocturnal  epilepsy  chloretone  (5  grains)  is  often 
a  useful  adjuvant  to  the  bromids.  Horse-nettle  (Solanum 
carolinense)  is  another  remedy  that  appears  to  increase  the 
activity  of  the  bromids.  From  J  to  i  fluidram  of  the  fluid 
extract  may  be  given  thrice  daily.  In  petit  mal  nitrogly- 
cerin (yto"  to  2V  gJ'^i^'')  is  sometimes  efiflcacious. 

Trephining  offers  some  hope  of  relief  in  certain  cases  of 
focal  epilepsy,  although  it  has  to  its  credit  less  than  4  per 
cent,  of  recoveries. 

The  Attack. — When  an  aura  is  perceived,  it  is  often  pos- 
sible to  arrest  the  paroxysm  by  the  inhalation  of  amyl 
nitrite.  Patients  may  provide  themselves  with  this  drug  in 
the  form  of  pearls  that  may  be  crushed  in  the  handkerchief. 
If  a  sensory  aura  is  felt  in  a  limb,  the  part  may  be  firmly 
grasped  or  encircled  with  a  light  ligature.  During  the 
attack  the  head  should  be  slightly  raised,  the  clothes 
loosened,  and  a  piece  of  cork  or  firm  rubber  pushed  be- 
tween the  teeth.  In  the  status  epilepticus  the  most  reliable 
measures   are   inhalations    of  chloroform,    ether,    or    amyl 


HYSTERIA.  439 

nitrite,  hypodermic  injections  of  hyoscin  (xJo"  g^^iri)  or  of 
morphin  (^  grain),  enemas  of  chloral  (20  to  30  grains),  and 
the  hot  bath. 

HYSTERIA. 

Definition. — A  psychoneurosis  characterized  by  in- 
creased impressionability  and  a  lack  of  self-control,  and 
manifested  by  a  train  of  symptoms  of  the  most  varied  char- 
acter. 

etiology. — Females  are  especially  predisposed,  although 
it  occasionally  develops  in  males.  It  is  most  common  in 
early  adult  life.  Heredity  is  an  important  etiologic  factor, 
the  disease  frequently  being  transmitted  through  hysteric, 
epileptic,  degenerate,  or  insane  parentage.  Faulty  home- 
training  and  education  also  do  much  to  foster  its  develop- 
ment. 

Traumatism,  prolonged  emotional  excitement,  such  as  wor- 
riment,  anxiety,  disappointment,  grief,  and  all  causes  that 
lower  the  vitality,  serve  to  excite  it  in  susceptible  individuals. 

Pathology. — No  causal  lesions  can  be  detected  after 
death. 

Symptoms. — The  various  manifestations  may  be  described 
under  three  heads  :  (i)  Motor,  (2)  sensory,  and  (3)  psychic. 

Motor  Phenomena. — Paralysis  not  infrequently  results  from 
hysteria  ;  it  may  take  the  form  of  a  hemiplegia,  paraplegia, 
or  monoplegia,  although  the  first  is  by  far  the  most  common. 
The  paralysis  is  generally  paroxysmal,  and  is  frequently 
associated  with  contractures  and  anesthesia.  The  affected 
muscles  do  not  waste. 

Local  paralysis  is  also  common  ;  thus  there  may  be  aphonia 
from  paralysis  of  the  vocal  cords  ;  dysphagia,  from  paralysis 
of  the  esophagus  ;  and  incontinence  of  urine,  from  paralysis 
of  the  bladder. 

Convulsive  seizures  are  common  manifestations  of  hysteria, 
and  may  closely  simulate  the  paroxysms  of  true  epilepsy, 
but  there  is  no  aura  ;  the  patient  usually  falls  in  a  comfort- 
able place  ;  consciousness  is  only  apparently  lost ;  the  tongue 
is  rarely  bitten  ;  the  eyes  are  partially  closed  ;  the  face  is  ex- 
pressive of  some  emotion ;  screaming  or  sobbing  is  of  fre- 


440 


DISEASES   OF   THE   NERVOUS  SYSTEM. 


quent  occurrence ;  the  movements  are  apt  to  be  tonic,  so 
that  the  patient  assumes  the  position  of  opisthotonos,  or  if 
clonic,  they  are  apt  to  be  violent  and  purposive;  the  seizures 
are  of  long  duration,  and  may  be  continued  for  several  hours, 
and  firm  pressure  over  the  ovaries  may  exaggerate  them. 

The  spasms  may  be  local ;  thus  there  may  be  retention  of 
urine  from  spasm  of  the  bladder ;  asthma,  from  spasm  of 
the  bronchi ;  hiccup,  from  spasm  of  the  diaphragm  ;  persistent 
vomiting,  from  spasm  of  the  stomach ;  dysphagia,  from 
spasm  of  the  esophagus  ;  and  a  "  phantom  tumor,"  from 
spasm  of  the  abdominal  muscles. 

Among  other  motor  phenomena  may  be  mentioned  obsti- 
nate tremors,  choreiform  movements,  and  contractures. 

Sensory  Phenomena. — There  may  be  a  complete  loss  of 
sensation  in  certain  parts,  as  of  one  side  of  the  body.  Anes- 
thesia without  other  nervous  phenomena  is  usually  hysteric. 
In  some  cases  tactile  sensation  is  preserved  and  there  is  a 
loss  only  of  thermic  or  painful  sensations.  The  anesthetic 
part  is  often  unusually  pale,  and  when  pricked  with  a  needle, 
may  fail  to  bleed  (ischemia). 

The  special  senses  may  be  involved  ;  thus  there  may  be 
contraction  of  the  field  of  vision,  complete  blindness,  loss 
of  smell,  loss  of  taste,  or  loss  of  hearing.  These  palsies  are 
usually  transient,  and  often  alterate  with  one  another. 

Instead  of  anesthesia,  there  may  be  hyperesthesia  or  pain. 
Severe  pain  in  the  stomach  may  simulate  gastralgia.  An 
exquisitely  painful  and  tender  condition  of  the  abdomen  may 
be  mistaken  for  peritonitis.  A  localized  pain  in  the  head, 
described  as  resembling  the  effect  of  a  nail  being  driven  into 
it,  is  termed  hysteric  claims.  The  joints  occasionally  become 
swollen  and  tender,  resembling  arthritis  (neuromimesis). 

Psychical  Pheno7nena. — Frequently  the  only  conspicuous 
mental  phenomenon  is  the  great  lack  of  will-power,  but 
generally  the  patients  are  more  or  less  excitable,  highly 
mercurial,  and  easily  moved  to  laughter  or  tears.  They 
frequently  manifest  a  great  fondness  for  sympathy,  and  this 
in  connection  with  their  weak  will-power  often  leads  them 
to  feign  symptoms  which  they  really  do  not  have.  Among 
the  more  serious  mental  manifestations  may  be  mentioned 
delirium,  ecstasy,  catalepsy,  and  trance. 


HYSTERIA.  441 

Treatment. — This  must  be  directed  both  to  the  mind 
and  the  body,  especially  to  the  former.  To  be  successful, 
the  physician  must  be  able  to  inspire  absolute  confidence 
and  faith  in  the  mind  of  the  patient.  She  must  be  impressed 
repeatedly  with  the  fact  that  her  condition  is  a  curable  one, 
and  that  with  her  thorough  cooperation  restoration  to  health 
will  certainly  follow.  To  intimate  that  her  symptoms  are 
feigned  or  are  wholly  within  her  control  is  a  grave  error.  In 
many  cases  no  method  of  treatment  proves  successful  until 
the  patient  has  been  removed  from  her  customary  surround- 
ings and  separated  from  her  sympathetic  relatives  and  friends. 

Suggestion  is  employed  consciously  or  unconsciously  in 
the  treatment  of  hysteria  by  every  successful  physician. 
Without  it  many  of  the  remedies  recognized  as  efficacious 
become  wholly  impotent.  Complete  hypnotism,  however, 
is  by  no  means  so  generally  useful  as  continuous  suggestion, 
and,  moreover,  in  the  event  of  failure,  seems  capable  6f  still 
further  lowering  the  will-power  and  of  increasing  the  emo- 
tional excitability. 

The  physical  condition  of  the  patient  must  not  be  neg- 
lected. General  measures,  such  as  hydrotherapy,  system- 
atic exercise  in  the  open  air,  massage,  and  electricity,  are 
valuable  aids  to  recovery.  In  grave  cases  the  treatment 
associated  with  the  name  of  S.  Weir  Mitchell  often  yields 
admirable  results.  It  consists  in  isolation  from  sympathizing 
friends  and  relatives;  abundant  feeding,  especially  with  milk; 
and  complete  rest  of  body  and  mind,  w^ith  passive  exercise 
obtained  by  massage  and  electricity. 

Except  to  meet  underlying  conditions  and  to  combat 
special  symptoms,  drugs  are  of  little  value.  Iron  and  arsenic 
are  useful  when  there  is  anemia.  Antispasmodics,  like 
valerian,  sumbul,  asafetida,  and  camphor,  are  serviceable  in 
allaying  abnormal  nervous  irritability. 

Such  combinations  as  the  following  may  prove  useful : 

R.    Arseni  trioxidi       • •  gr-  ss 

Ferri  sulphatis  exsiccati 

Extract!  sumbul aa  gr.  xx 

Asafoetidse gr-  xl.— M. 

Fiant  pilulae  No.  xx. 

SiG. — One  three  or  four  times  a  day. 


442  DISEASES   OF   THE   NERVOUS  SYSTEM. 

Or: 

^  .     Quininse  valeratis 

Zinci  valeratis 

Ferri  valeratis aa  gr.  xxiv.  — M. 

Fiant  pilulse  No,  xxiv. 
SiG. — One  pill  thrice  daily. 

Occasionally  more  powerful  sedatives,  like  the  bromids, 
phenacetin,  and  chloralamid,  may  be  demanded,  but  the 
continuous  use  of  such  remedies  is  always  to  be  condemned. 
Such  drugs  as  morphin,  alcohol,  and  chloral  are  distinctly 
dangerous. 

When  hysteria  is  complicated  by  local  disease,  special 
treatment  will  be  required,  but  no  operation  should  ever  be 
performed  for  the  relief  of  nervous  symptoms  unless  there 
exists  an  actual  organic  lesion. 

Cojividsions. — Isolation  of  the  patient  is  imperative.  Firm 
pressure  over  the  ovarian  region  is  often  successful.  The 
affusion  of  cold  water  over  the  face  is  useful.  Inhalations 
of  amyl  nitrite,  or  even  of  chloroform,  may  be  employed  if 
necessary.  Strong  faradic  currents  applied  to  the  spine  are 
occasionally  efficacious. 

Anesthesia  is  best  treated  by  electricity,  especially  by 
the  faradic  brush.  Static  electricity,  owing  to  the  pro- 
found mental  impression  which  it  produces,  is  also  useful. 
Hyperesthesia  and  pain  often  yield  to  the  continuous  or 
interrupted  galvanic  current.  In  paralysis  the  patient  should 
be  instructed  how  to  regain,  by  long-continued  practice,  the 
use  of  the  affected  part.  Swedish  movements,  massage,  and 
faradization  are  useful  adjuvants.  In  aphonia  the  faradic 
current,  applied  by  means  of  special  electrodes,  is  the  most 
reliable  remedy.  In  contractures  the  most  useful  measures 
are  massage,  passive  movements,  and  faradization. 


NEURASTHENIA. 

(Nervous  Prostration.) 

Definition. — Afunctional  disease  characterized  by  a  lack 
of  nervous  energy  and  increased  sensitiveness  to  external 
impressions. 


NE  URASTHENIA. 


AA^ 


Ktiology. — The  causes  are  much  the  same  as  those  that 
give  rise  to  hysteria.  Men  are  often  affected.  Overwork, 
prolonged  mental  strain,  and  depressing  emotions  are  com- 
mon exciting  causes. 

Symptoms. — Cerebral  Symptoms. — These  include  de- 
pression of  spirits,  indisposition,  inability  to  concentrate  the 
mind  on  one  subject  for  any  length  of  time,  insomnia,  ver- 
tigo, headache,  irritability  of  temper,  introspection,  and  mor- 
bid fears. 

Spinal  Symptoms. — Sometimes  these  predominate,  when 
the  condition  is  termed  spinal  irritation.  The  chief  mani- 
festations are :  Pain  in  the  back,  spots  of  tenderness  along 
the  spine,  weakness  of  the  extremities,  great  prostration  after 
moderate  exertion,  and  various  subjective  phenomena,  such 
as  numbness,  tingling,  formication,  and  neuralgic  pains. 

Gastro-intestiiial  Symptoms. — These  consist  of  anorexia, 
coated  tongue,  indigestion,  and  constipation. 

Circulatory  Symptoms. — These  include  palpitation,  tachy- 
cardia, pseudoangina,  cold  extremities,  and  sometimes  violent 
pulsation  of  the  abdominal  aorta. 

Sexual  Symptoms. — In  females  there  is  often  amenorrhea 
or  dysmenorrhea,  and  in  males  impotence  or  spermatorrhea. 

Diagnosis. — The  diagnosis  is  rarely  difficult.  Before 
relegating  a  case  to  this  class,  care  must  be  taken  to  exclude 
organic  disease  and  snch  general  disorders  as  gout,  diabetes, 
and  anemia. 

Hysteria. — This  affection  may  be  distinguished  by  the 
abrupt  onset,  the  intermittent  character  of  the  symptoms, 
and  such  stigmata  as  paralysis,  anesthesia,  contractures, 
emotional  outbreaks,  convulsions,  and  the  globus  hystericus. 

Prognosis. — When  the  cause  can  be  removed  and  the 
patient  controlled,  the  prognosis  is  favorable. 

Treatment. — The  treatment  is  largely  hygienic  and 
dietetic,  and  must  vary  considerably  in  different  cases.  When 
there  has  been  inactivity,  regulated  physical  exercise  will  be 
of  great  value  ;  on  the  other  hand,  the  weak  and  anemic  will 
require  rest.  In  the  latter  case  the  plan  of  treatment  intro- 
duced by  S.  Weir  Mitchell,  and  known  as  the  "  rest-cure," 
often  gives  brilliant  results.     In  all  cases  careful  attention 


444 


DISEASES   OF  THE  NERVOUS  SYSTEM. 


must  be  given  to  the  diet,  bathing,  and  clothing,  and  the 
patient  assured  that  he  is  suffering  from  no  incurable  disease. 
Frequent  bathing  with  salt  water,  followed  by  friction  of  the 
skin,  will  often  add  to  the  general  vigor.  Tobacco  and 
alcohol  must  be  interdicted,  and  tea  and  coffee  used  very 
sparingly.  Tonics,  like  iron,  arsenic,  quinin,  strychnin,  and 
phosphorus,  are  often  indicated. 

ACUTE  CHOREA, 

(Sydenham's  Chorea ;   Chorea  Minor ;  St.  Vitus's  Dance.) 

Definition. — A  nervous  affection  occurring  especially  in 
children,  and  characterized  by  irregular,  spasmodic  move- 
ments that  increase  under  excitement  and  cease  during  sleep. 

etiology. — The  large  majority  of  cases  occur  in  children 
between  the  ages  of  five  and  fifteen,  though  adults,  especially 
women  during  or  after  pregnancy,  are  occasionally  attacked. 
More  females  are  affected  than  males.  Heredity  sometimes 
plays  an  important  role.  Children  of  a  nervous  tempera- 
ment are  especially  susceptible.  Fright  or  shock  is  very 
frequently  an  exciting  factor.  In  about  one-fifth  of  all  cases 
there  is  an  antecedent  history  of  rheumatism  between  which 
disease  and  chorea  there  appears  to  be  some  relation. 
Chorea  is  most  common  in  the  spring  months. 

Pathology. — It  is  customary  to  look  upon  chorea  as  a 
neurosis,  since  no  constant  lesions  have  been  discovered  to 
account  for  its  clinical  manifestations.  In  some  cases  emboli 
in  the  minute  cerebral  vessels  have  been  discovered,  but 
their  relation  to  chorea  has  not  yet  been  determined.  A 
microbic  origin  has  been  suggested. 

Syttiptoms. — The  first  manifestations  are  usually  rest- 
lessness and  awkwardness  in  movement.  The  child  cannot 
remain  still,  but  is  constantly  raising  its  shoulders,  jerking 
its  head,  twisting  its  fingers,  or  shuffling  its  feet.  Frequently 
these  symptoms  develop  so  insidiously  that  the  disease  is  not 
recognized,  and  the  child  is  punished  for  being  fidgety. 

When  the  disease  is  fully  established,  the  disorderly  move- 
ments become  more  marked.  They  may  be  confined  to  one 
member  or  may  involve  the  entire  body.     When  the  facial 


CHOREA.  445 

muscles  are  affected,  the  most  grotesque  expressions  are 
produced  ;  involvement  of  the  arms  may  interfere  with  eating 
and  dressing;  when  the  legs  suffer,  the  gait  becomes  jerking 
and  stumbling ;  involvement  of  the  larynx  causes  stammer- 
ing, and  spasm  of  the  muscles  of  deglutition  induces  dif- 
ficult swallowing  and  choking  spells.  When  the  attention  is 
directed  to  the  movements,  they  invariably  grow  worse,  but 
they  diminish  during  repose  and  cease  entirely  during  sleep. 
Sometimes,  in  addition  to  the  involuntary  movements,  there 
is  a  distinct  loss  of  power  in  the  affected  micmbers.  The 
general  health  is  usually  more  or  less  impaired.  The  child 
is  anemic ;  the  temper  is  irritable  ;  and  the  mental  power 
deficient.  Auscultation  of  the  heart  often  detects  a  murmur 
that  may  be  an  expression  either  of  anemia  or  of  compli- 
cating endocarditis. 

Chorea  Insaniens. — In  this  form  the  movements  are  so 
violent  that  the  patient  is  unable  to  walk,  eat,  or  even  to  lie 
in  bed.  Fever  develops,  and  ultimately  the  mind  becomes 
delirious.  Death  frequently  results  from  exhaustion.  This 
form  is  usually  observed  in  adults,  and  especially  in  primi- 
parae. 

Diagnosis. — The  recognition  of  chorea  is  rarely  attended 
with  difficulty.  Disseminated  spinal  sclerosis  may  be  distin- 
guished by  the  presence  of  nystagmus,  a  scanning  speech, 
increased  reflexes,  and  a  rhythmic  tremor  that  is  excited 
only  by  movement. 

Huntingdon's  Chorea. — This  disease  is  usually  hereditary ; 
it  rarely  develops  before  the  age  of  thirty ;  it  runs  a  chronic 
course  ;  and  it  is  characterized  by  slower  and  more  inco- 
ordinate movements  than  occur  in  acute  chorea,  by  progres- 
sive mental  failure,  and  by  a  marked  suicidal  tendency. 

Other  conditions  producing  choreiform  movements  have 
been  considered  on  page  366. 

Complications. — Vegetative  endocarditis  occurs  in  from 
30  to  40  per  cent,  of  all  cases.  Pericarditis  is  occasionally 
seen. 

Prognosis. — In  simple  chorea  recovery  usually  follows 
in  the  course  of  two  or  three  months.  Death  from  heart 
complications  is  a  rare  termination.     Relapses  are  not  in- 


446  DISEASES   OF   THE   NERVOUS  SYSTEM. 

frequent.  Chorea  insaniens  frequently  terminates  fatally 
through  exhaustion. 

Treatment. — Rest  of  body  and  mind  is  an  essential  ele- 
ment of  the  treatment.  The  child  should  be  taken  from 
school  and  placed  under  the  most  favorable  hygienic  con- 
ditions. Amusement  in  the  open  air  when  the  weather  is 
fine  is  to  be  recommended.  As  the  child  is  generally 
anemic,  iron  is  indicated  in  the  majority  of  cases.  Among 
the  special  remedies  arsenic  holds  the  first  place.  Fowler's 
solution  may  be  given  in  doses  of  two  drops  thrice  daily, 
gradually  increased  to  eight  or  ten  drops  thrice  daily. 
When  arsenic  fails,  cimicifuga  should  be  tried.  A  dose  of 
lo  minims  of  the  fluid  extract  may  be  given  after  meals 
and  gradually  increased  to  \  fluidram  or  more.  When  the 
movements  are  very  violent  and  interfere  with  sleep,  re- 
course must  be  had  to  chloral,  bromids,  hyoscin,  or  mor- 
phin,  but  these  drugs  should  not  be  used  unless  the  symp- 
toms are  of  great  severity. 

Chorea  Insaniens. — Powerful  sedatives  like  hyoscin, 
chloral,  and  morphin  are  required  to  allay  the  violent  ex- 
citability and  jactitation.  Inhalations  of  chloroform  are 
sometimes  useful.  Stimulants  are  almost  always  required. 
When  the  patient  is  unable  to  swallow,  no  time  should  be 
lost  in  resorting  to  forced  feeding.  Severe  cases  of  chorea 
complicating  pregnancy  will  call  for  the  induction  of  prema- 
ture labor. 

NEURALGIA. 

Definition. — A  functional  disease  of  the  nerve-trunks, 
characterized  by  paroxysms  of  intense  pain. 

Ktiology. — It  is  a  disease  of  adults.  Women  are  much 
more  frequently  affected  than  men.  Heredity  is  an  impor- 
tant etiologic  factor.  It  is  frequently  an  expression  of 
anemia.  It  may  result  from  the  action  of  some  toxic  agent 
in  the  blood ;  thus  it  is  common  in  malaria,  rheumatism, 
gout,  syphilis,  and  chronic  lead-poisoning.  It  may  be  caused 
by  reflex  irritation  ;  thus  a  trifacial  neuralgia  may  depend 
on  caries  of  the  teeth  or  eye-strain.  In  some  cases  neural- 
gia results  from  organic  disease  of  the  nerve-center ;  thus 


NEURALGIA.  44;^ 

obstinate  trifacial  neuralgia  may  be  dependent  upon  some 
degeneration  or  tumor  of  the  Gasserian  ganglion. 

Exposure  to  cold  and  wet  frequently  acts  as  an  exciting 
cause  in  susceptible  persons. 

Pathology. — The  pathologic  condition  upon  which  neu- 
ralgia depends  is  unknown.  In  many  cases,  no  doubt,  it  is 
a  manifestation  of  neuritis. 

Symptoms. — Certain  prodromes  frequently  give  warn- 
ing of  an  approaching  attack  ;  these  are  chilliness,  depres- 
sion of  spirits,  and  perhaps  tingling  in  the  part  to  be 
affected.  The  chief  symptom  is  intense  pain,  which  is 
usually  of  a  sharp,  stabbing  character.  The  area  supplied 
by  the  affected  nerve  is  generally  hyperesthetic,  and  palpa- 
tion may  detect  spots  of  exquisite  tenderness  where  the 
nerve  makes  its  exit  through  a  bony  canal  or  fibrous  sheath 
— points  douloureux  of  Valleix.  In  some  cases  the  pain  is 
attended  with  tremors  or  spasms  of  the  muscles.  Inspec- 
tion of  the  part  usually  reveals  nothing  abnormal,  but  occa- 
sionally distinct  sweUing  is  observed. 

The  attack  lasts  from  a  few  minutes  to  many  hours,  and 
its  subsidence  may  be  marked  by  the  passage  of  a  large 
amount  of  pale  urine.  The  interval  between  the  paroxysms 
varies  in  different  cases ;  it  is  frequently  several  weeks  or 
months.  It  is  noteworthy  that  the  attacks  often  recur  at 
regular  intervals. 

Trifacial  Neuralgia  {Tic  Douloureux ;  Prosopalgia). — In 
this  variety  the  pain  involves  one  or  more  branches  of  the 
trifacial  nerve.  The  tender  points  correspond  to  the  supra- 
orbital, infra-orbital,  and  mental  foramina.  Violent  spasms  of 
the  muscles  are  frequently  observed.  In  long-standing  cases 
the  hair  on  the  affected  side  may  become  coarse  and  bleached. 

httercostal  Neuralgia. — In  this  variety  the  pain  follows 
the  course  of  the  intercostal  nerves.  It  is  frequently  asso- 
ciated with  an  eruption  of  herpes  zoster.  Spots  of  tender- 
ness may  be  detected  near  the  vertebral  columns,  in  the 
middle  of  the  nerve,  and  near  the  sternum.  The  possible 
dependence  of  intercostal  neuralgia  upon  spinal  caries  or 
thoracic  aneurysm  must  not  be  forgotten. 

Occipital  neuralgia  involves  the  upper  cervical  nerves.  A 
spot  of  tenderness  may  be  discovered  midway  between  the 


448  DISEASES   OF  THE  NERVOUS  SYSTEM. 

mastoid  process  and  the  upper  cervical  vertebra,  ^ms 
form  of  neuralgia  may  also  be  an  expression  of  spinal  caries. 

Sciatica  has  been  described  elsewhere. 

Diagnosis. — Neuritis. — The  continuous  pain,  the  ten- 
derness along  the  entire  nerve,  the  presence  of  paresthesia, 
anesthesia,  paresis,  and  wasting  will  serve  to  distinguish 
neuritis  from  neuralgia. 

The  lightning-pains  of  locomotor  ataxia  must  not  be  mis- 
taken for  neuralgia.  The  aboHshed  patellar  reflex,  the  loss 
of  coordination,  and  the  Argyll-Robertson  pupil  in  the 
former  will  indicate  the  diagnosis. 

Prognosis. — For  the  attack  the  prognosis  is  good ;  for 
permanent  cure,  it  must  be  guarded.  When  the  cause  can 
be  removed,  the  prognosis  is  favorable. 

Treatment. — The  Interval. — Careful  search  should  be 
made  for  an  exciting  cause,  which,  if  found,  must  be  re- 
moved. The  teeth,  eyes,  nose,  gastro-intestinal  tract,  urine, 
and  blood  should  be  carefully  examined. 

When  the  disease  is  associated  with  anemia,  iron  and 
arsenic  will  be  indicated.  If  there  is  any  suspicion  of 
syphilis,  mercury  and  iodids  should  be  tried.  When  a 
malarial  element  is  present,  quinin  may  effect  a  cure.  When 
rheumatism  is  an  etiologic  factor,  salicylates  and  alkahs  may 
prove  beneficial.  In  gouty  subjects  much  may  be  expected 
from  regulation  of  diet,  systematic  exercise,  and  the  admin- 
istration of  alkalis.  In  chronic  lead-poisoning  iodids  are 
indispensable. 

All  influences  that  tend  to  induce  a  morbid  excitability 
of  the  nerves  or  of  their  centers — mental  or  physical  fatigue, 
emotional  excitement,  sexual  excess,  overindulgence  in 
tobacco,  tea,  coffee,  or  alcohol — should  be  removed  as  far 
as  possible. 

In  every  case  we  must  endeavor  to  improve  the  general 
nutrition,  which  is  almost  always  disturbed.  The  measures 
to  be  employed  for  this  purpose  include  an  abundance  of 
fresh  air,  proper  food,  regular  hours,  adequate  protection 
from  the  vicissitudes  of  weather,  systematic  exercise,  fre- 
quent bathing  with  friction,  and  the  use  of  such  tonics  as 
iron,  arsenic,  cod-liver  oil,  and  hypophosphites. 


NEURALGIA.  449 

^„    ,^i-lowing  combination  is  often  useful: 

Ijt .     Quininse  sulphatis gr.  xxiv 

Arseni  trioxidi gr.  ss 

"  "  Ferri  reducti ^ss 

Calcii  glycerophosphatis ^iss. — M. 

Pone  in  capsulas  No.  xxiv. 

SiG. — One  capsule  after  meals. 

Finally,  when  all  other  measures  fail,  recourse  may  be  had 
to  surgical  interference.  Nerve-stretching  and  nerve-section 
are  the  operations  usually  performed.  Lasting  benefit, 
however,  is  rarely  obtained  from  either  operation.  In  obsti- 
nate trifacial  neuralgia  removal  of  the  Gasserian  ganglion 
usually  affords  permanent  relief,  though  the  operation  is 
not  without  danger. 

The  Attack. — Heat,  dry  or  moist,  may  be  applied  for  its 
soothing  effect.  A  liniment  of  aconite  or  of  chloroform  is 
sometimes  efficacious.  Menthol  and  chloral  camphor  are  use- 
ful in  neuralgia  of  superficial  nerves  when  the  pain  is  slight. 
Acupuncture  and  aquapuncture  are  effective,  but  are  not 
suitable  for  use  about  the  face.  In  obstinate  cases  active 
counterirritation  by  means  of  blisters  or  the  thermocautery 
will  be  found  a  potent  remedy.  In  trifacial  neuralgia  the 
blisters  may  be  applied  behind  the  ear. 

Among  the  internal  remedies  most  worthy  of  confidence 
may  be  mentioned  phenacetin,  antipyrin,  acetanilid  (5  to 
10  grains),  bromids,  cannabis  indica,  croton  chloral,  caffein, 
gelsemium,  and  salicylic  compounds.  Morphin  is  undoubt- 
edly the  most  certain  means  we  possess  of  affording  tem- 
porary relief,  but  on  account  of  the  danger  of  inducing  the 
opium  habit  it  should  be  employed  only  as  a  last  resort. 
Combinations  of  a  bromid  with  phenacetin  may  often  be 
prescribed  advantageously.  Croton  chloral,  in  doses  of 
from  5  to  10  grains,  and  tincture  of  gelsemium,  in  doses  of  10 
minims  or  more,  are  occasionally  serviceable  in  trifacial  neu- 
ralgia. Caffein  (3  to  5  grains)  is  often  efficacious.  Combina- 
tions of  caffein  with  phenacetin  or  with  bromids  in  many  cases 
do  more  good  than  single  drugs.  Neuralgia  brought  on  by 
exposure   to    cold  and  wet  is  favorably  influenced  by  the 

29 


450  DISEASES    OE   THE   NERVOUS  SYSTEM. 

salicylates.    In  such,  the  following  combination  will  be  found 
of  value  : 

K: .      Acetphenetidini 

Salophen aa  ^i^iss 

CodeiriEe  sulphatis gr.  iij. — M. 

Fiant  chartulse  No.  xij. 

SiG. — One  powder  every  two  or  three  hours. 

MIGRAINE. 

(Hemicrania ;  Megrim  ;   Sick-headache.) 

Definition. — A  neurosis  characterized  by  periodic  at- 
tacks of  intense  headache,  usually  unilateral  and  often  associ- 
ated with  visual,  gastric,  and  vasomotor  disturbances. 

^^tiology. — It  is  frequently  hereditary.  It  is  more  com- 
mon in  women  than  in  men.  It  usually  develops  in  early 
life.  Anemia,  gastric  disturbances,  gout,  eye-strain,  men- 
strual disorders,  overwork,  and  prolonged  excitement  pre- 
dispose to  it. 

Symptoms. — Prodromes,  such  as  restlessness,  depres- 
sion, and  malaise  are  common.  The  attack  is  often  ushered 
in  with  visual  disturbances,  such  as  flashes  of  light,  dimness 
of  vision,  or  hemianopsia.  The  pain  is  severe  and  generally 
limited  to  the  temporofrontal  region  of  one  side,  though  it 
sometimes  spreads  until  it  involves  the  whole  head.  The 
patient  is  very  sensitive  to  light  and  sound,  and  during  the 
attack  usually  confines  herself  to  a  darkened  room.  Nausea 
and  vomiting  are  frequently  present.  In  some  cases  the 
temporal  artery  is  contracted,  the  face  is  pale,  and  the  pupil 
large ;  in  others  the  artery  is  dilated,  the  face  is  flushed, 
and  the  pupil  small.  The  duration  of  the  attacks  varies 
from  a  few  hours  to  several  days.  In  the  intervals,  which 
are  often  of  definite  duration,  the  patient  may  be  quite  well. 

Less  frequent  symptoms  are  vertigo,  hallucinations  of 
sight,  cramps  of  the  facial  muscles,  tingHng  or  numbness  in 
one  hand,  partial  aphasia,  and  paresis  of  the  ocular  muscles. 

Prognosis. — Perfect  cure  is  rare,  but  many  cases  are 
improved  by  treatment.  The  attacks  often  cease  spontane- 
ously at  middle  life. 

Treatment. — In  the  interval  the  treatment  is  that  of 
neuralgia.     Cannabis  indica  is  sometimes  of  value.    From  a 


PARALYSIS  AGITANS. 


451 


quarter  to  a  half  a  grain  of  the  extract  may  be  given  for 
several  weeks.     Little  recommends  : 

R.    Sodii  arsenatis gr.  ij 

Extract!  cannabis  indicae gr.  vj 

Extract!  belladonnge gr.  viij. — M. 

Fiant  pilulae  No.  xxiv. 

SiG. — One  pill  twice  daily. 

The  Attack. — The  patient  should  be  kept  at  rest  in  a 
quiet,  darkened,  well-ventilated  room.  Antipyrin,  phenac- 
etin,  caffein,  bromids,  and  salicylic  compounds  are  the 
most  useful  remedies.  They  may  often  be  combined  with 
advantage,  as  in  the  following  formulas : 

li .    Caffeinae  citratse gr-  xij 

Acetphenetidini ^j 

Sodii  bromidi ^ij. — M. 

Fiant  chartulse  No.  xij. 

SiG. — One  powder  every  two  hours. 

Or: 

U.    Salophen ^iss 

Acetphenetidini ^j 

Caffeinas  citratae gr.  xij. — M. 

Fiant  chartulse  No.  xij. 

SiG. — One  every  two  hours. 

PARALYSIS  AGITANS. 

(Parkinson's  Disease;  Shaking  Palsy.) 

Definition. — A  chronic  nervous  disease,  characterized 
by  a  gradually  spreading  tremor,  muscular  weakness  and 
rigidity,  and  a  peculiar  gait,  termed  festination. 

]^tiolog"y. — Advanced  life,  a  neuropathic  tendency, 
mental  strain,  heredity,  and  exposure  to  cold  and  wet  are 
predisposing  factors.  It  sometimes  develops  suddenly 
after  intense  mental  or  emotional  excitement. 

Pathology. — The  pathology  is  unknown.  The  lesions 
found — degeneration  of  arterioles,  perivascular  sclerosis,  pig- 
mentation of  ganglionic  cells — are  similar  to  those  induced 
by  senility. 

Symptoms. — In  some  cases  the  onset  is  abrupt,  but 
more  commonly  the  disease  develops  insidiously.  A  tremor 
appears,  usually  in  the  fingers,  and  gradually  spreads  until 


452  DISEASES   OF   THE   NERVOUS  SYSTEM. 

it  involves  all  the  extremities  and  sometimes  the  neck  and 
head.  At  first  the  tremor  may  be  paroxysmal,  but  as  the 
disease  advances  it  becomes  almost  continuous.  Excite- 
ment increases  it,  but  it  is  notworthy  that  physical  effort 
temporarily  diminishes  or  checks  it.  The  face  becomes  ex- 
pressionless and  the  speech  slow  and  measured.  Later, 
muscular  rigidity  develops,  and  the  head  is  bowed,  the 
body  bent  forward,  the  arm  flexed,  the  thumbs  turned  into 
the  palms  and  grasped  by  the  fingers,  and  the  knees  slightly 
bent.  At  this  time  the  gait  is  characteristic  ;  the  steps  grow 
faster  and  faster,  the  body  inclines  more  and  more  forward 
until  the  patient  falls,  finds  support  in  some  neighboring 
object,  or  straightens  himself  by  a  suprerhe  effort  of  the 
will.  The  term  festination  has  been  applied  to  this  peculiar 
gait.  Occasionally  a  tendency  to  fall  backward — i^etropulsion 
— replaces  festination.  The  rigidity  and  muscular  weakness 
render  all  movements  slow  and  stiff. 

Intelligence  is  usually  good.  There  is  no  anesthesia,  but 
there  are  various  manifestations  of  paresthesia,  such  as 
numbness  and  tingling  and  a  sensation  of  heat.  In  some 
cases  free  perspiration  has  been  observed. 

Diagnosis. — The  tremor,  rigidity,  weakness,  flexion  of 
the  body  and  members,  lack  oi  facial  expression,  and  festina- 
tion are  the  diagnostic  features.  In  some  cases  the  tremor 
is  absent.  Paralysis  agitans  must  be  distinguished  from 
disseminated  sclerosis.  In  the  latter  the  tremor  is  absent 
when  the  patient  is  quiet,  and  is  made  worse  by  efforts  to 
control  it ;  cerebral  symptoms  are  generally  present ;  nys- 
tagmus is  often  noted ;  and  the  attitude  and  gait  are  entirely 
different  from  those  of  paralysis  agitans. 

Prognosis. — Recovery  rarely,  if  ever,  occurs.  In 
some  cases,  after  reaching  a  certain  point,  the  disease 
remains  stationary.  The  progress  is  slow  and  the  dura- 
tion indefinite. 

Treatment. — Measures  intended  to  improve  the  tone  of 
the  system  are  indicated ;  these  are  :  A  regulated  diet,  rest 
of  body  and  mind,  frequent  bathing  followed  by  friction  of 
the  skin,  and  the  use  of  some  tonics  as  iron,  arsenic,  and 


ARTISANS'    CRAMP,  453 

phosphorus.  The  rigidity  and  tremors  are  sometimes  im- 
proved by  massage  and  electricity.  Among  the  remedies 
recommended  for  the  tremors  are  bromid  of  potassium, 
hyoscyamin  (y^^-  grain),  hyoscin  (yl^  grain),  and  duboisin 
(tot  ^^  "To  §^^^^)>  t>ut  the  improvement  following  their  use 
is  only  slight  and  temporary. 

ARTISANS*  CRAMR 

Definition, — A  spasmodic  affection  of  the  muscles  in- 
duced by  prolonged  work  requiring  delicate  coordination, 
and  occurring  only  in  the  performance  of  that  particular 
work. 

!l^tiology. — It  is  more  common  in  men  than  in  women, 
and  the  nervous  temperament  predisposes  to  its  develop- 
ment. The  occupations  in  which  it  is  most  apt  to  occur  are 
writing,  piano-playing,  sewing,  and  telegraphing. 

Pathology. — The  disease  is  evidently  not  peripheral,  for 
when  the  other  hand  is  substituted,  the  condition  soon  de- 
velops in  that  member.  It  is  probably  dependent  upon 
unnatural  irritability  of  the  nerve-centers. 

WRITERS'  CRAMP. 
(Graphospasm;  Scriveners'  Palsy.) 

Symptoms. — The  condition  usually  begins  with  a  sense 
of  fatigue,  weight,  or  actual  pain  in  the  affected  muscles. 
Soon  the  fingers  are  seized  with  a  tonic  or  clonic  spasm 
whenever  the  pen  is  grasped  (spastic  form).  In  some  cases 
the  hand  when  put  into  use  becomes  the  seat  of  a  decided 
tremor  (tremulous  form) ;  in  a  third  group  of  cases  the 
chief  phenomena  are  excessive  weakness  and  fatigue  which 
disappear  as  soon  as  the  pen  is  laid  aside  (paralytic  form). 

Prognosis. — Guardedly  favorable.  The  disease  is  obsti- 
nate, but  cure  generally  follows  protracted  rest. 

Treatment. — Absolute  rest  is  the  essential  element  of 
treatment.  The  general  condition  should  be  improved  by 
iron,  arsenic,  strychnin,  and  cod-liver  oil.  Massage,  elec- 
tricity, and  passive  movements  give  good  results. 


454  DISEASES   OF  THE   NERVOUS  SYSTEM. 

TETANY. 

(Tetanilla ;  Intermittent  Tetanus.) 

Definition. — A  comparatively  rare  disease  characterized 
by  continuous  or  intermittent  tonic  spasms,  especially  of 
the  extremities. 

etiology. — Tetany  is  a  disease  chiefly  of  infants  and 
young  adults.  In  infants  it  is  usually  associated  with  rick- 
ets, gastro-intestinal  disorders,  or  the  specific  fevers.  In 
adults  it  has  developed  in  gastro-intestinal  infections,  espec- 
ially gastrectasis,  in  acute  infectious  diseases,  in  pregnancy 
or  lactation,  in  poisoning  by  certain  drugs,  such  as  chloro- 
form or  morphin  ;  or  it  has  followed  thyroidectomy.  An 
epidemic  form  has  also  been  described,  but  some  of  the 
outbreaks  seem  to  have  been  hysteric. 

Pathogenesis. — There  is  reason  to  believe  that  the 
disease  is  due  to  certain  endogenous  poisons  which  nor- 
mally are  neutralized  by  the  secretion  of  parathyroid  glands. 

Symptoms. — The  patient  is  seized  with  bilateral  tonic 
spasms,  beginning  in  the  hands  or  feet  and  spreading  up- 
ward. In  many  cases  all  four  extremities  are  attacked. 
The  muscles  of  the  trunk  and  face  are  sometimes  involved, 
but  those  of  the  jaw  only  rarely.  The  spasms  are  usually 
intermittent,  though  they  may  be  continuous  and  last  for 
days  or  even  weeks.  They  are  sometimes  attended  by 
pain.  Laryngismus  stridulus  is  not  uncommon  in  children. 
As  was  pointed  out  by  Trousseau,  pressure  on  the  nerve- 
trunks  and  blood-vessels  of  the  affected  limb  will  reproduce 
the  contractions.  Sometimes  the  mechanical  irritability  of 
the  motor  nerves  is  so  increased  that  a  mere  tap  will  excite 
spasm  (Chvostek's  phenomenon).  The  electric  irritability 
of  the  motor  nerves  and  muscles  is  also  increased  (Erb's 
phenomenon).  Not  rarely  the  cramps  are  accompanied  by 
slight  fever  and  edema  of  the  hands  and  feet. 

Diagnosis. — In  tetanus  a  source  of  infection  is  usually 
found;  trismus  or  lockjaw  appears  early;  and  the  muscles 
of  the  back  are  more  contracted  than  those  of  the  limbs. 

Hysteria  may  be  distinguished  from  tetany  by  the  history, 
the  emotional  disturbances,-  the  unilateral  character  of  the 
spasms,  and  the  absence  of  Trousseau's  sign. 


THOMSEN'S  DISEASE  -RAYNAUD' S  DISEASE.       455 

Prognosis. — The  outlook  is  generally  good,  though  in 
tetany  associated  with  gastrectasis  or  following  thyroidec- 
tomy the  mortahty  is  high. 

Treatment. — The  cause  should  be  sought  for  and 
removed  if  possible.  Thyroid  and  parathyroid  extracts 
have  been  very  serviceable  in  some  cases.  Surgical  inter- 
vention is  indicated  when  there  is  gastrectasis.  Warm  baths 
are  useful.  Among  the  sedatives,  the  bromids  are  most 
serviceable.  In  severe  cases  it  may  be  necessary  to  use 
hyoscin,  chloral,  or  morphin. 

THOMSEN^S  DISEASE. 

(Congenital  Myotonia.) 

Definition. — A  disease  confined  to  certain  families,  and 
characterized  by  tonic  spasms  of  the  muscles,  induced  by 
voluntary  movements. 

Etiology. — The  disease  is  usually  congenital,  and  trans- 
mitted from  one  generation  to  another.  Several  members 
of  the  same  family  are  commonly  affected. 

Pathology. — Unknown. 

Symptoms.— The  disease  appears  in  early  childhood, 
and  is  manifested  by  tonic  spasm  of  the  muscles  upon  every 
attempt  at  voluntary  motion.  This  is  especially  marked 
after  periods  of  inactivity.  In  a  few  moments  the  rigidity 
wears  away  and  the  movements  become  free.  From  re- 
peated contractions  the  muscles  become  firm  and  extremely 
well  developed.  Under  electric  stimulation  the  muscles 
contract  and  relax  slowly.  The  disease  is  incurable,  but 
shows  no  tendency  to  prove  fatal. 

RAYNAUD'S  DISEASE* 

(Symmetric  Gangrene.) 

Definition.— A  vasomotor  neurosis  characterized  by 
local   anemia,  congestion,  and  gangrene. 

Btiology. — The  cause  is  unknown.  The  disease  is 
believed  to  be  dependent  upon  spasm  of  the  peripheral 
arterioles.- 


456  DISEASES    OF   THE   NERVOUS  SYSTEM. 

Symptoms. — In  the  first  stage  the  affected  part  becomes 
extremely  pale,  cold,  and  anesthetic  {local  syncope).  After 
a  variable  time  the  part  becomes  purple,  livid,  and  intensely 
painful  {local  asphyxia).  Such  attacks  may  be  excited  by 
cold,  and  come  and  go  without  damaging  the  part.  Oc- 
casionally the  disease  advances  to  the  third  stage,  in  which 
congestion  gives  way  to  dry  gangrene.  Symmetric  parts, 
as  a  finger  on  each  hand,  a  toe  on  each  foot,  or  the  lobes 
of  the  ears,  are  usually  affected.  Hemoglobinuria  may 
occur  in,  or  replace,  an  attack. 

Progfnosis. — The  attacks  persist,  but  life  is  rarely  en- 
dangered. 

Treatment. — Patients  liable  to  attacks  should  be  well 
protected  against  cold.  Tonics  are  often  indicated.  Fre- 
quent bathing  followed  by  friction  is  useful.  Raynaud 
advises  the  use  of  the  continuous  current — one  pole  over 
the  spine  and  the  other  over  the  affected  area.  Nitro- 
glycerin may  prove  useful. 

ACUTE  ANGIONEUROTIC  EDEMA* 

Definition. — A  neurosis  characterized  by  transient  cir- 
cumscribed edema  developing  without  obvious  cause. 

i^tiology. — Beyond  a  distinct  hereditary  tendency  noth- 
ing is  known  of  its  cause.  According  to  Quincke,  there  is 
a  temporary  vasomotor  dilatation  of  the  vessels,  followed  by 
the  transudation  of  serum. 

Symptoms. — Edematous  swelling  suddenly  appears  in 
some  part  of  the  body,  particularly  in  the  face  and  hands. 
Coincident  with  the  edema  there  may  be  marked  gastro- 
intestinal symptoms,  such  as  vomiting,  gastralgia,  and  colic. 
The  disease  is  allied  to  urticaria  and  the  latter  may  precede 
the  outbreak. 

The  attacks  usually  occur  at  intervals  of  a  few  weeks. 

Prognosis. — The  disease  generally  proves  very  obstinate, 
but  unless  it  involves  the  larynx,  it  does  not  endanger  life. 

Treatment. — General  tonics,  like  iron,  quinin,  and 
strychnin,   are   sometimes   useful. 


MUSCULAR   DYSTROPHIES.  457 

TROPHIC  DISORDERS,  SUNSTROKE,  AND 
INTOXICATIONS. 

MUSCULAR  DYSTROPHIES^ 

Definition. — An  atrophic  condition  of  the  muscles  de- 
veloping in  early  life  and  not  dependent  upon  any  lesion  in 
the  nervous  system. 

l^tiologfy. — The  disease  usually  manifests  itself  before 
puberty.  It  is  more  common  in  males  than  in  females.  It 
is  frequently  transmitted  from  generation  to  generation,  and 
several  members  of  the  same  family  may  be  similarly^ 
affected. 

Pathology. — No  lesion  in  the  cord  or  nerves  is  observed. 
Gowers  regards  the  disease  as  of  developmental  origin. 
Microscopic  examination  of  the  muscles  reveals  atrophy  of 
their  fibers  and  an  unnatural  amount  of  fat  and  connective 
tissue.  When  the  latter  elements  are  considerably  increased, 
a  pseudohypertrophy  results  (pseudomuscular  hypertrophy). 

Varieties. — The  following  types  are  recognized:  (i) 
Pseudomuscular  hypertrophy;  (2)  Erb's  juvenile  dys- 
trophy ;  (3)  Landouzy-Dejerine  type. 

Pseudomuscular  Hypertropliy. — This  form  begins  in  chil- 
dren between  the  second  and  seventh  year.  The  first 
symptom  to  attract  attention  is  weakness  of  the  muscles  ; 
the  child  is  awkward,  stumbles,  and  in  walking  seeks  sup- 
port. As  the  paralysis  increases  the  muscles,  particularly 
those  of  the  calf,  thigh,  buttock,  and  back,  enlarge.  The 
upper  extremities  are  less  frequently  affected.  When  the 
child  assumes  the  erect  posture,  the  feet  are  wide  apart,  the 
belly  protrudes,  and  the  spinal  column  shows  a  marked 
curvature  with  the  convexity  forward.  The  manner  of 
rising  from  the  recumbent  position  is  characteristic:  He 
straightens  himself  either  by  grasping  the  knees  or  by 
resting  the  hands  on  the  floor  in  front  of  him,  extending  the 
legs,  and  pushing  the  body  backward.  The  gait  is  waddling 
in  character. 

The    electric  contractility    of   the    muscles    is    gradually 


458  DISEASES   OF   THE   NERVOUS  SYSTEM. 

reduced,  but  the  reaction  of  degeneration  is  not  present. 
There  are  no  fibrillary  twitchings  in  the  muscles.  The 
knee-jerk  is  lessened  or  abolished.  There  are  no  mental  or 
sensory  disturbances. 

In  the  course  of  a  few  years  the  paralysis  becomes  so 
marked  that  the  patient  is  unable  to  leave  his  bed ;  the  en- 
largement of  the  muscles  is  followed  by  atrophy  ;  and  finally 
death  results  from  some  intercurrent  disease  or  inflamma- 
tion of  the  lungs  induced  by  the  weakened  respiratory 
power. 

Erb's  Juvenile  Dystrophy. — This  form  usually  develops 
between  the  ages  of  twelve  and  sixteen.  The  muscles  of 
the  shoulder  are  first  affected.  The  wasting  may  be  pre- 
ceded by  hypertrophy. 

In  chronic  poliomyelitis  (progressive  muscular  atrophy  of 
spinal  origin),  the  symptoms  come  on  later  in  life,  hered- 
itary or  family  influences  are  rarely  present,  the  small  mus- 
cles of  the  hand  are  first  affected,  and  the  wasting  is  asso- 
ciated with  fibrillary  twitchings.  In  multiple  neuritis 
paralysis  precedes  the  wasting,  sensory  symptoms  are 
usually  present,  and  the  history  reveals  a  definite  cause. 

Landouzy-Dejerine  Type. — This  type  usually  develops  in 
early  childhood  and  is  characterized  by  bilateral  atrophy  of 
the  facial  muscles.  It  differs  from  hilbar  palsy  in  that  it 
does  not  involve  the  tongue  or  the  muscles  of  deglutition. 

Prognosis  and  Treatment. — The  disease  is  curable, 
but  the  progress  is  slow.  Massage,  electricity,  and  grad- 
uated exercise  may  be  followed  by  temporary  improve- 
ment. 

FACIAL  HEMIATROPHY* 

(Unilateral  Progressive  Atrophy  of  the  Face.) 

Definition. — A  rare  affection,  characterized  by  progres- 
sive wasting  of  tissues — bones  and  soft  parts — on  one  side 
of  the  face. 

i^tiology. — The  disease  usually  develops  in  childhood. 
It  has  been  excited  by  injury  of  the  face. 

Pathology. — In  the  few  cases  examined  chronic  tri- 
geminal neuritis  has  been  discovered. 


ACROMEGAL  V. 


459 


S5^mptoms. — The  first  phenomenon  is  often  discoloration 
of  the  skin  ;  this  is  soon  followed  by  a  slow  wasting  of  all 
the  tissues  on  the  affected  side  of  the  face.  The  hair  falls, 
the  eye  recedes,  and  the  teeth  drop  out. 

Prognosis. — The  disease  is  progressive  and  incurable. 

ACROMEGALY. 

(Marie's  Disease ;  Pachyacria.) 

Definition. — A  nutritional  disease,  characterized  by  en- 
largement of  the  bones  and  overlying  tissues,  chiefly  of  the 
hands,  feet,  and  face. 

;^tiology. — Unknown.  It  usually  develops  in  early  life. 
Marie  attributed  it  to  a  loss  of  function  of  the  pituitary  bod}'. 

Pathology. — Examination  of  the  bones  reveals  a  true 
hypertrophy,  particularly  of  the  cancellous  structures.  In 
many  cases  the  pituitary  body  has  been  found  to  be  the  seat 
of  simple  hypertrophy,  degeneration,  adenoma,  or  sarcoma; 
in  a  few  the  thymus  or  thyroid  gland  has  been  diseased. 

Symptoms. — The  hands  and  feet  are  considerably  en- 
larged, especially  in  breadth  ;  the  fingers  and  toes  are  stumpy 
and  the  nails  are  flat  and  small.  Hypertrophy  of  the  infe- 
rior maxillary  bone  leads  to  elongation  of  the  face  and  pro- 
trusion of  the  lower  jaw.  The  lips  are  large  and  everted. 
Among  occasional  symptoms  may  be  mentioned  spinal 
curvature,  polyuria,  glycosuria,  persistent  headache,  deaf- 
ness, blindness  from  atrophy  of  the  optic  nerve,  loss  of 
sexual  power,  and,  in  women,  menstrual  disorders. 

Diagnosis. — Acromegaly  might  be  mistaken  for  myx- 
edema, but  in  the  latter  only  the  soft  parts  are  involved ;  the 
skin  is  firm  and  adherent,  instead  of  soft  and  mobile,  as  in 
acromegaly  ;  and  the  face  is  round. 

In  Paget's  osteitis  deformans  the  long  bones  are  especially 
involved,  and  are  not  only  enlarged,  but  considerably  de- 
formed, and  the  face  has  a  peculiar  triangular  shape. 

Prognosis. — The  affection  is  incurable,  but  the  duration 
may  be  indefinite.  Acute  cases  lasting  two  or  three  years 
are  usually  associated  with  sarcoma  of  the  pituitary  body. 

Treatment. — So  far,  remedies  have  been  futile. 


460  DISEASES   OF  THE  NERVOUS  SYSTEM. 

SUNSTROKE. 

(Heat-stroke;  Thermic  Fever;  Coup  de  Soleil;  Insolation;  Heat- 
exhaustion.) 

Definition. — An  affection  resulting  from  exposure  to  ex- 
cessive heat. 

Varieties. — Two  varieties  are  observed :  thermic  fever 
and  heat- exhaustion. 

THERMIC  FEVER. 

il^tiology. — The  exciting  cause  is  exposure  to  intense 
heat,  natural  or  artificial.  Bodily  fatigue  and  intemperance 
are  important  predisposing  factors.  It  is  probable  that  the 
excessive  heat  leads  to  the  production  of  toxic  substances 
that  disturb  the  heat-regulating  centers  in  the  brain.    - 

Pathology. — After  death  from  thermic  fever  rigor  mortis 
develops  early  and  is  marked.  The  various  organs,  espe- 
cially the  brain,  are  deeply  congested.  The  left  ventricle  is 
firmly  contracted,  and  the  right  is  dilated  and  filled  with 
blood.  The  blood  is  dark  and  uncoagulated.  Microscopic 
examination  of  the  tissues  reveals  parenchymatous  degen- 
eration or  cloudy  swelling. 

Symptoms. — Prodromes  are  frequently  present  and  con- 
sist of  exhaustion,  vertigo,  nausea,-  and  headache.  These 
symptoms  are  followed  by  coma,  and  in  this  state  the  face 
is  flushed ;  the  eyes  are  injected ;  the  skin  is  dry  and  burn- 
ing;  the  temperature  ranges  from  106°  to  112°  F.;  the 
pupils  are  contracted ;  the  respirations  are  rapid  and  noisy ; 
and  the  pulse  is  full  and  rapid.  Unless  the  temperature 
soon  falls,  the  respirations  become  shallow,  the  pulse 
weakens,  and  death  results  in  a  few  hours.  There  is  a  very 
mahgnant  form  in  which  the  patient  is  suddenly  stricken 
comatose  and  dies  in  a  few  hours  from  cardiac  failure. 

Sequelse. — They  include  chronic  meningitis  ;  epilepsy ; 
insanity ;  failure  of  memory ;  and  extreme  sensitiveness  to 
high  temperature. 

Diag^nosis. — The  conditions  under  which  the  coma  has 
developed,  together  with  the  extremely  high  temperature  of 


A  L  COHOL  ISM.  46 1 

the  body,  will  serve  to  distinguish  sunstroke  from  apoplexy, 
alcoholism,  and  uremia. 

Prognosis. — This  should  be  very  guarded.  Probably 
40  per  cent,  perish. 

Treatment. — The  patient  should  be  promptly  placed  in 
a  bath  of  iced  water  and  should  be  rubbed  with  ice.  Ice- 
water  enemas  are  also  useful.  The  subcutaneous  or  intra- 
venous injection  of  normal  salt  solution  has  proved  effica- 
cious in  some  cases.  Packard  and  others  have  found 
blood-letting  (10  to  20  ounces)  very  effective  in  some 
cases.  Feebleness  of  the  pulse  is  not  necessarily  a  contra- 
indication, as  the  circulation  often  improves  during  the 
operation. 

HEAT-EXHAUSTION. 

Pathology. — According  to  Wood,  heat-exhaustion  de- 
pends on  a  vasomotor  paresis,  as  a  result  of  which  there  is 
a  determination  of  blood  from  the  brain  and  surface  of  the 
body  to  the  great  blood-vessels  of  the  abdomen. 

Symptoms. — -The  mind  is  dazed,  but  consciousness  is 
not  lost ;  the  surface  is  pale  and  cold ;  the  skin  is  moist ;  the 
respirations  are  shallow  and  hurried ;  and  the  pulse  is  rapid 
and  feeble. 

Prognosis. — Recovery  generally  follows  under  appro- 
priate treatment. 

Treatment. — The  patient  should  be  covered  with  hot 
blankets,  and  hot  bottles  should  be  placed  near  the  feet. 
Brandy,  ammonia,  and  strong  coffee  are  useful  stimulants. 
Strychnin  hypodermically  is  an  efficient  remedy. 

ALCOHOLISM. 

(Inebriety.) 

Acute  Alcoholism. — The  ingestion  of  large  quantities  of 
alcohol  produces  the  following  symptoms  :  Flushing  of  the 
face,  mental  excitement,  quickening  of  the  pulse  and  respi- 
ration ;  then  incoherent  speech,  delirium,  dilated  pupils,  loss 
of  coordination,  subnormal  temperature,  vomiting,  and, 
finally,  stupor  and  coma.  Not  infrequently  the  coma  is 
interrupted  by  convulsive   seizures.     In    most  cases,  if  the 


462  DISEASES   OF  THE  NERVOUS  SYSTEM. 

dose  has  not  been  too  large,  recovery  follows  in  a  day  or 
two. 

Chronic  alcoholism  is  characterized  by  disturbed  sleep, 
fine  tremors,  mental  impairment,  injection  of  the  eyes,  red- 
ness of  the  nose,  and  the  symptoms  of  gastro-intestinal 
catarrh.  When  the  habit  is  long  continued,  degenerative 
and  cirrhotic  changes  in  the  heart,  blood-vessels,  Hver,  and 
kidneys  are  apt  to  develop. 

A  common  complication  of  chronic  alcoholism  is  delirium 
tremens,  which  is  generally  excited  by  temporary  excess, 
an  injury,  or  some  "acute  intercurrent  disease,  especially 
pneumonia.  It  is  manifested  by  great  mental  excitement, 
insomnia,  incoherent  speech,  tremors,  disordered  intellect, 
and  terrifying  hallucinations  of  sight  or  hearing.  The 
pulse  is  rapid  and  feeble,  the  appetite  is  lost,  the  bowels  are 
constipated,  and  the  temperature  is  slightly  elevated.  In 
favorable  cases  convalescence  follows  in  a  few  days,  but  not 
infrequently  typhoid  symptoms  develop  and  the  attack  ends 
in  death. 

Among  other  sequels  of  dipsomania  may  be  mentioned 
pneumonia,  chronic  meningitis,  multiple  neuritis,  amblyopia, 
epilepsy,  and  dementia. 

Diagnosis. — The  coma  of  alcoholism  must  be  distin- 
guished from  the  coma  of  other  diseases.  The  history,  the 
absence  of  paralysis,  the  subnormal  temperature,  the  fact 
that  the  patient  can  be  aroused  by  screaming  in  the  ear  or 
by  firm  pressure  over  some  sensitive  spot  like  the  supra- 
orbital notch,  the  odor  on  the  breath,  and  the  absence  of 
other  cause  will  usually  prevent  an  error  in  diagnosis. 

Delirium  tremens  is  recognized  by  the  history,  restless- 
ness, delirium,  tremors,  and  terrifying  hallucinations. 

Tlie  tremors  of  chronic  alcoholism  may  be  recognized  by 
the  history,  the  associated  evidence  of  alcoholism,  and  by 
the  fact  that  they  are  worse  in  the  morning  and  improve 
after  the  use  of  the  stimulant. 

Prognosis. — In  acute  alcoholism  the  prognosis  should 
be  guardedly  favorable.  In  delirium  tremens  recovery  gen- 
erally follows  unless  there  is  great  debility,  hi  alcoholic 
pneumonia  the   outlook  is   grave ;  recovery  is   exceptional. 


AL  CO  HOLISM.  46  3 

Lt  alcoholic  neuritis  the  symptoms  usually  subside  under 
appropriate  remedies  and  abstinence  from  the  stimulant. 

In  chi^'onic  alcoholism  the  prognosis  is  generally  unfavor- 
able. When  the  habit  is  fully  established,  it  is  rarely  per- 
manently broken  ;  temporary  improvement  is  only  too  often 
followed  by  a  relapse. 

Treatment. — Acute  Alcoholism. — The  stomach  should 
be  emptied  by  the  stomach-pump,  a  stimulating  emetic,  or 
the  hypodermic  injection  of  apomorphin  (y^q  grain).  If  the 
coma  persists  and  the  pulse  weakens,  cardiac  stimulants, 
like  ammonia,  strychnin,  and  digitalis,  should  be  admin- 
istered hypodermically.  Douching  and  flagellation  may 
also  be  employed  to  arouse  the  patient. 

Treatment  of  Delirium  Tremens. — As  there  has  usually 
been  a  complete  abstinence  from  food  during  the  debauch 
leading  to  the  delirium,  nutritious  foods  are  always  neces- 
sary, and  the  best  are  milk  with  lime-water  and  highly 
seasoned  beef-tea.  Sleep  must  be  secured  by  chloral  (20 
grains),  hyoscin  (y-^^-  grain),  potassium  bromid  (i  dram),  or 
paraldehyd  (J  to  I  fluidram).  Active  catharsis  should  be 
encouraged.  When  the  pulse  is  weak,  strychnin  and  digi- 
talis will  be  found  useful  stimulants.  In  many  cases  phy- 
sical restraint  will  be  required ;  it  may  be  secured  by  strap- 
ping the  patient  to  the  bed  with  sheets.  Should  profound 
stupor  develop,  the  application  of  a  blister  to  the  back  of 
the  neck  or  a  few  light  touches  of  the  actual  cautery  will 
often  serve  to  arouse  the  patient. 

Chronic  Alcoholism. — It  is  necessary  that  alcohol  shall  be 
withdrawn  ;  the  rapidity  with  which  this  can  be  accomplished 
will  depend  on  the  circumstances.  In  most  cases  the  tempta- 
tion to  drink  is  so  strong  that  confinement  in  an  inebriate 
asylum  is  essential  to  the  success  of  the  treatment.  Various 
substitutes  have  been  recommended  for  alcohol,  among 
which  may  be  mentioned  bromid  of  potassium,  chloral, 
cocain,  hyoscin,  and  cannabis  indica.  As  a  rule,  they 
accomplish  little  beyond  quieting  the  patient  and  occasion- 
ally securing  sleep.  The  diet  should  be  nutritious,  and 
carefully  adapted  to  the  condition  of  the  stomach,  which  is 
usually  the  seat  of  chronic  catarrh.  Tonics,  Uke  iron,  quinin. 


464  DISEASES   OF  THE  NERVOUS  SYSTEM 

and    strychnin,  are   often   indicated.      Graduatec     physical 
exercise  is  sometimes  of  decided  value. 

CHRONIC  OPIUM  POISONING* 

(Morphinomania . ) 

SjTtnptoms. — The  symptoms  resulting  from  the  habitual 
use  of  opium  are  an  irresistible  craving  for  the  drug,  loss 
of  flesh  and  strength,  tremors,  anemia,  a  peculiar  sallow 
complexion,  anorexia,  deranged  digestion,  a  tendency  to 
diarrhea,  disturbed  sleep,  mental  depression,  irritability,  and 
a  characteristic  propensity  for  lying  and  deceiving. 

Treatment.^ — Isolation  in  a  special  institution  or  asylum 
is  almost  imperative.  As  a  rule,  the  drug  should  be  with- 
drawn rapidly,  but  in  aggravated  cases  not  too  abruptly, 
for  fear  of  collapse.  The  diet  should  consist  of  nutritious, 
easily  digested  food.  Strychnin,  while  it  is  without  specific 
action,  is  often  extremely  valuable  for  its  stimulating  effect. 
Bromids  and  cannabis  indica  are  sometimes  useful  in  amelio- 
rating the  distress  that  follows  the  withdrawal  of  opium. 
Sulphonal,  paraldehyd,  and  chloretone  are  the  best  hyp- 
notics. Massage,  graduated  exercise,  and  the  Turkish  bath 
are  useful  roborant  measures  in  the  convalescent  stage. 

CHRONIC  LEAD-POISONING- 

(Plumbism;  Saturnism.) 

etiology. — Chronic  lead-poisoning  may  be  brought 
about  by  the  too  prolonged  use  of  the  salts  of  lead  for 
medicinal  purposes,  but  it  is  much  more  frequently  induced 
in  workmen  who  are  exposed  to  the  fumes  or  dust  of  lead, 
or  who  handle  the  metal  or  paints  containing  it.  It  may 
follow,  also,  the  accidental  introduction  of  lead  into  the 
system  through  drinking-water,  articles  of  food,  hair-dyes, 
and  cosmetics.  Occasionally  it  results  from  the  use  of 
water  that  has  been  carried  through  lead  pipes  or  has  been 
stored  in  cisterns  lined  with  lead. 

Pathology. — The  muscles  are  degenerated,  and  the 
peripheral  nerves  frequently  reveal  evidences  of  chronic  neu- 
ritis.     In  cases  associated  with  marked  muscular  atrophy 


.^,  CHRONIC  LEAD-POISONING.  aJo^ 

there  \  -/  be  also  degeneration  of  the  ganglionic  cells  in 
the  gray  liorns  of  the  spinal  cord. 

SyiHTitoms. — The  following  are  the  chief  manifestations  : 
Anen.  v^ith  granular  degeneration  (basophilic)  of  the  red 
cells ;  severe  colicky  pains  centering  around  the  umbilicus, 
with  retraction  and  rigidity  of  the  abdominal  walls ;  consti- 
pation ;  a  blue  line  on  the  gums  near  the  insertion  of  the 
teeth,  due  to  the  deposition  of  a  sulphuret  of  lead  ;  paralysis  ; 
tremors;  intense  headache;  pains  in  the  joints  (arthralgia); 
arteriosclerosis ;  chronic  interstitial  nephritis ;  and  grave 
cerebral  symptoms  (encephalopathies). 

The  Paralysis. — This  usually  attacks  the  muscles  supplied 
by  the  musculospiral  nerve, — the  extensors  of  the  fingers 
and  of  the  wrist, — causing  the  so-called  ''wrist-drop."  The 
affected  muscles  ultimately  atrophy  and  yield  the  reactions 
of  degeneration.  Occasionally  other  muscles  are  involved, 
such  as  the  extensors  of  the  legs,  the  recti  of  the  eye,  and 
the  adductors  of  the  larynx.     Sensation  is  not  affected. 

Encephalopathies. — These  are  among  the  more  rare  mani- 
festations of  plumbism,  and  consist  of  convulsions,  coma, 
delirium,  intense  headache,  and  blindness  from  atrophy  of 
the  optic  nerves. 

Prognosis. — Guardedly  favorable. 

Treatment. — Prophylaxis  consists  in  absolute  cleanli- 
ness ;  the  use  of  respirators  in  lead  factories ;  the  avoidance 
of  eating  in  an  atmosphere  laden  with  the  dust  of  the 
metal ;  and  in  the  occasional  use  of  Epsom  salts. 

The  curative  treatment  consists  in  the  administration  of 
iodid  of  potassium  (5  to  10  grains  thrice  daily)  and  the  use 
of  sulphur  baths.  Constipation  should  be  relieved  by  Ep- 
som salts.  The  colic  may  require  the  hypodermic  injection 
of  moVphin  and  atropin  and  the  application  of  hot  fomenta- 
tions to  the  abdomen.  The  paralysis  generally  yields  to 
massage,  the  constant  current,  and  hypodermic  injections 
of  strychnin. 

30 


DISEASES  OF  THE  SKIN  AND  ITS 
APPENDAGES. 


THE  COLOR  OF  THE  SKIN, 

Pallor  as  a  pemiajient  co?iditioii  is  generally  an  expres- 
sion of  anemia ;  but  it  should  be  borne  in  mind  that  in  some 
cases  the  surface  is  pale  when  the  blood  is  normally  rich  in. 
corpuscles  and  hemoglobin ;  and  that  in  other  cases  the  sur- 
face has  a  natural  color  when  the  blood  is  considerably  defi- 
cient in  corpuscles  and  hemoglobin.  It  follows,  therefore, 
that  an  absolute  diagnosis  of  anemia  must  rest  on  an  analy- 
sis of  the  blood. 

Pallor  as  a  temporary  condition  may  result  from  emo- 
tional excitement,  exposure  to  extreme  cold,  shock,  syn- 
cope, or  collapse. 

Yellowness  of  the  skin  may  result  from  jaundice,  in 
which  case  the  conjunctivae  will  also  be  yellow  and  the  urine 
will  contain  bile.  Yellowness  may  also  result  from  chlorosis 
or  pernicious  anemia,  and  in  these  cases  the  normal  color  of 
the  conjunctivae,  the  associated  symptoms  of  the  disease, 
and  the  absence  of  bile  in  the  urine  will  indicate  the  cause. 

Whiteness  of  the  Skin. — A  milk-white  hue  over  ex- 
tensive areas  may  be  observed  in  albinism,  vitiligo,  and  in 
leprosy. 

Dark-brown  or  gray  discoloration  of  the  skin  is 
observed  in  the  following  conditions : 

Addison's  Disease. — In  this  affection  the  skin  has  a  bronzed 
appearance,  which  is  especially  marked  on  exposed  parts  ; 
the  buccal  mucous  membrane  may  also  reveal  discolored 
plaques,  and  there  are,  in  addition,  anemia,  prostration,  and 
gastric  irritability. 
466 


GLOSSY  SKIN. 


467 


Argyria. — This  term  is  applied  to  the  dark-gray  discolora- 
tion of  the  exposed  parts  that  follows  the  prolonged  use  of 
nitrate  of  silver.  The  discoloration  is  due  to  a  deposition 
of  the  oxid  of  silver  and  is  more  or  less  permanent.  It  is 
said  to  be  preceded  by  a  dark  Hne  on  the  gums,  similar 
to  the  one  observed  in  chronic  lead-poisoning.  Formerly, 
when  nitrate  of  silver  was  used  extensively  in  the  treatment 
of  epilepsy,  it  was  not  an  uncommon  condition. 

Vagabondisnius. — This  term  is  applied  to  the  dark-brown 
discoloration  of  the  skin  that  follows  prolonged  exposure  to 
the  weather,  uncleanliness,  and  perhaps  the  irritation  of  the 
skin  resulting  from  pediculosis. 

Blueness  of  the  skin  as  a  permanent  condition  is  gen- 
erally an  expression  of  cyanosis. 

HARDNESS  OR   INDURATION  OF  THE  SKIN, 

Induration  of  the  skin  is  observed  in  scleroderma.  In  this 
affection  the  skin  is  tense,  hide-bound,  and  more  or  less  pig- 
mented. Induration  is  also  observed  in  myxedema.  In  this 
condition  the  skin  is  swollen,  as  in  edema,  but  it  is  firm,  in- 
elastic, and  does  not  pit  on  pressure.  In  addition  the  fea- 
tures are  peculiarly  broadened  and  the  mental  power  is  im- 
paired. Circumscribed  patches  of  induration  are  observed 
in  morphea.  The  circumscribed  patches,  with  hyperemic  or 
pigmented  borders,  and  the  smooth,  shiny,  atrophied  condi- 
tion of  the  skin  are  the  diagnostic  features. 

Edema^  or  dropsy  of  the  subcutaiteous  tissues,  when  ex- 
treme, may  also  cause  induration. 

A  brawny,  indurated  condition  of  the  muscles,  especially 
of  the  legs,  is  frequently  observed  in  scurvy.  It  probably 
results  from  a  sanguineous  exudation.  The  anemia,  pur- 
puric spots,  and  spongy,  bleeding  gums  will  aid  in  the 
diagnosis. 

GLOSSY  SKIN, 

"  Glossy  Skin!' — This  term  was  applied  by  Paget  to  indi- 
cate a  smooth,  atrophied,  and  shiny  appearance  of  the  skin. 
It  is  most  frequently  observed  after  inflammation  or  injury 
of  the  nerve-trunks.      It  is  sometimes  associated  with  an 


468    DISEASES   OE   THE   SKIN  AND   ITS  APPENDAGES. 

intense  burning  pain  to  which  Mitchell  has  given  the  name 

causalgia. 

ENLARGEMENT  OF  THE  SUPERFICIAL  VEINS, 

Enlargement  of  the  superficial  veins  may  result  from 
chronic  heart,  lung,  or  liver  disease  or  from  the  pressure  of 
a  tumor  or  aneurysm  on  deep-seated  veins.  As  a  general 
condition  it  may  be  congenital  and  result  from  occlusion  of 
the  deep  veins. 

"  Caput  Medusae.**— This  term  is  applied  to  a  circle  of 
dilated  veins  surrounding  the  umbilicus.  It  is  indicative  of 
obstruction  to  the  portal  circulation,  and  may  result  from 
atrophic  cirrhosis  of  the  liver,  from  thrombosis  of  the  portal 
vein,  or  from  the  pressure  of  a  tumor  on  the  portal  vein. 

CUTANEOUS  EMPHYSEMA. 

Cutaneous  emphysema  consists  in  an  escape  of  air  into 
the  cellular  tissue.  It  is  manifested  by  a  diffuse,  pallid  swell- 
ing of  the  skin,  which  crackles  on  palpation  and  which  pits 
on  pressure  ;  but  unlike  edema,  the  depression  immediately 
disappears  when  the  finger  is  withdrawn.  It  may  result — 
(i)  From  traumatism  of  the  lungs,  as  in  gunshot  wounds  of 
the  chest  or  fracture  of  the  ribs.  (2)  From  rupture  of  the 
esophagus,  stomach,  intestines,  larynx,  trachea,  or  lungs. 
The  rupture  of  these  organs  is  usually  due  to  ulceration, 
such  as  may  occur  in  cancer  of  the  esophagus,  tuberculous 
cavity  of  the  lung,  or  purulent  pleurisy. 

ABNORMAL  CONDITIONS  OF  THE  NAILS. 

Atrophy  of  the  Nails. — The  nails  may  become  dry, 
brittle,  discolored,  and  cracked  in  organic  disease  of  the 
spinal  cord  ;  after  inflammation  or  injury  of  the  peripheral 
nerves  ;  after  prolonged  febrile  diseases,  like  typhoid  fever ; 
and  in  certain  affections  of  the  skin  that  involve  the  matrix 
of  the  nail,  as  eczema,  psoriasis,  and  ringworm. 

Curving"  of  the  Nails. — Incurvation  of  the  nails  is  gen- 
erally associated  with  clubbing  of  the  terminal  phalanges. 
It  is  observed  in  phthisis,  chronic  cardiac  disease,  and  in 
many  wasting  diseases. 


CUTANEOUS  ERUPTIONS.  4^9 

Onychia. — Inflammation  of  the  matrix  of  the  nail  may 
result  from  injury;  from  syphilis;  from  organic  disease  of 
the  spinal  cord,  as  locomotor  ataxia ;  from  arthritis  de- 
formans ;  and  from  cutaneous  affections  involving  the  matrix, 
as  leprosy,  ringworm,  and  eczema. 

CUTANEOUS  ERUPTIONS. 

Macules. — Macules  are  discolored  spots  that  are  neither 
elevated  nor  depressed. 

A  general  red  macular  eruption  is  observed  in  the  follow- 
ing conditions : 

Syphilis. — Secondary  syphilis  may  manifest  itself  as  an 
eruption  of  small  red  macules.  They  are  usually  abundant 
and  frequently  cover  the  entire  body ;  they  lack  subjective 
symptoms  ;  they  are  usually  associated  with  the  history  or 
with  the  evidences  of  syphiHs,  such  as  the  scar  of  the 
chancre,  bone-pains,  alopecia,  swollen  glands,  and  sore 
throat. 

Erythema  multiforme  may  manifest  itself  as  a  macular 
eruption,  but  the  macules  are  usually  associated  with  dark- 
red  papules  or  tubercles.  The  multiformity  of  the  lesions  ; 
their  preference  for  the  extremities  ;  their  appearance  in  suc- 
cessive crops  ;  the  short  duration  of  each  lesion  ;  the  absence 
of  subjective  phenomena,  such  as  itching  and  burning ;  and 
the  presence  of  rheumatic  pains  are  the  diagnostic  fea- 
tures. 

Pityriasis  Rosea. — The  eruption  is  especially  found  on  the 
trunk  ;  the  lesions  are  rose-red  in  color  ;  they  are  slightly 
scaly,  the  scales  being  dry ;  subjective  phenomena  are  gen- 
erally absent ;  and  the  duration  is  a  few  weeks. 

Pediculosis  Corporis. — Lice  may  produce  a  minute  red  or 
purple  eruption.  The  small  size  of  the  lesions ;  their  con- 
finement to  the  covered  parts  ;  the  intense  itching  and  the 
presence  of  scratch-marks  ;  and  the  discovery  of  pediculi  on 
the  clothes  are  the  diagnostic  features. 

Rotheln. — This  affection  produces  a  macular  or  maculo- 
papular  rash  that  disappears  in  two  or  three  days  by  slight 
desquamation.     The    moderate    fever,   sore  throat,  swollen 


470  DISEASES   OF  THE  SKIN  AND  ITS  APPENDAGES. 

cervical  glands,  and  history  of  contagion  will  assist  in  the 
diagnosis. 

Accidental RasJies. — Local  inflammations  like  tonsillitis  and 
acute  gastritis  and  certain  drugs  and  foods  occasionally  pro- 
duce a  macular  rash. 

Purpuric  spots  or  hemorrhagic  macules  (petechise)  result 
from  minute  extravasations  of  blood  into  the  skin. 

A  purpuric  eruption  is  observed  in  the  following  condi- 
tions : 

Purpni'a  Hceinori'Jiagica  {Morbus  Maculosus  Werlhofii). — 
This  affection  occurs  especially  in  children ;  it  is  associated 
with  fever  and  bleeding  from  the  mucous  membranes,  and 
generally  runs  a  course  of  one  or  two  weeks. 

Scurvy. — This  disease  results  from  a  deprivation  of  fresh 
vegetables,  and  is  associated  with  spongy,  bleeding  gums, 
great  weakness,  and  a  brawny  induration  of  the  muscles. 

RJieumatisni. — Occasionally  an  eruption  of  purpuric  spots 
appears  in  rheumatic  subjects.  It  is  usually  associated  with 
pains  in  the  limbs,  but  fever  is  generally  absent. 

Peliosis  RJicumatica  i^ScJidnlein' s  Disease). — This  is  an 
acute  affection,  characterized  by  purpuric  spots,  urticaria, 
sore  throat,  moderate  fever,  and  an  inflammation  of  the 
joints  resembling  rheumatism.  By  some  the  disease  is  re- 
garded as  a  manifestation  of  rheumatism. 

Extrerne  Anemia. — A  petechial  rash  is  not  uncommon  in 
pernicious  anemia,  leukocythemia,  cancer,  and  advanced 
Bright's  disease.  The  history  and  the  associated  symptoms 
of  the  original  disease  will  indicate  the  diagnosis. 

Certain  Infectious  Diseases. — In  typhus  fever  a  purpuric 
eruption  appears  on  the  fourth  or  fifth  day.  In  cerebro- 
spinal meningitis  the  eruption  is  frequently  petechial.  In 
malignant  measles  and  malignant  smallpox  the  rash  is  often 
hemorrhagic.  In  acute  yellow  atrophy  of  the  liver  and  in 
ulcerative  endocarditis  a  petechial  eruption  is  frequently  ob- 
served. 

Poisoning  from  Certain  Substances. — Poisoning  from  phos- 
phorus, the  virus  of  venomous  snakes,  mercury,  and  anti- 
pyrin  may  be  associated  with  an  eruption  of  purpura. 

Pediculosis  and  Kindred  Affections. — Body-lice,  bedbugs, 


CUTANEOUS  ERUPTIONS.  \J\ 

and  fleas  produce  petechial  lesions  that  are  surrounded  by 
slight  areolae.  The  itching,  scratch-marks,  and  discovery  of 
the  parasite  are  the  diagnostic  features. 

Brown  macules  are  observed  in  : 

Lentigo  or  Freckle. — The  spots  are  small,  and  are  found 
especially  on  exposed  parts — face,  neck,  shoulders,  and 
hands. 

Chloasma. — Dark  spots  may  result  from  irritation  of  the 
skin  from  the  action  of  chemicals,  heat,  scratches,  or  blisters. 
They  are  sometimes  noted  in  general  diseases,  like  Addison's 
disease  and  syphilis.  They  also  occur  in  primary  affections 
of  the  skin,  as  vitiligo,  morphea,  scleroderma,  and  leprosy. 

Mole  or  Ncevus  Pig'inentosa. — Moles  consist  in  congenital 
deposits  of  pigment  on  various  parts  of  the  body. 

White  or  pale  yellow  macules  are  observed  in : 

Vitiligo. — Apart  from  the  absence  of  pigment,  the  skin  is 
normal  in  appearance  and  function.  An  excess  of  pigment 
is  generally  noted  at  the  periphery  of  the  white  patches. 

Leprosy. — In  this  condition  there  are  structural  changes 
in  the  skin  and  anesthesia  in  addition  to  the  white  appear- 
ance. 

Morphea. — In  the  late  stage  of  this  affection  the  circum- 
scribed patches  are  white  or  yellow.  The  structure  of  the 
skin  is  altered,  and  the  periphery  of  the  patches  is  distinctly 
hyperemic. 

Facial  Hemiatrophy. — The  onset  of  this  disease  may  be 
marked  by  the  appearance  of  a  yellow  or  white  spot  on  one 
side  of  the  face. 

Diffuse  Brythema  or  Inflammation  of  the  Skin. — 
Diffuse  erythema  or  inflammation  of  the  skin  may  result 
from : 

The  Action  of  Certain  Drugs  (Dermatitis  Medicamentosa). — 
Belladonna,  quinin,  chloral,  cubebs,  salicyHc  acid,  and  arsenic 
may  produce  a  diffuse  red  rash. 

Scarlet  Fever. — The  history  of  contagion,  high  fever,  sore 
throat,  swollen  glands,  rapid  pulse,  and  the  punctiform 
character  of  the  rash  will  indicate  the  diagnosis. 

Rotheln. — In  some  cases  of  rotheln  the  eruption  is  red 
and  diffuse.     The    history,  slight    fever,  mild  catarrh,  and 


472  DISEASES   OF   THE   SKIN  AND   ITS  APPENDAGES. 

marked  swelling  of  the  postcervical  glands  will  suggest 
rotheln. 

Local  irritation  from  traumatism,  excessive  heat,  poisonous 
plants,  or  drugs  often  produces  erythema. 

Erythema  Intertrigo. — This  occurs  where  two  cutaneous 
surfaces  come  in  contact.  The  part  is  red,  moist,  and  some- 
times macerated.     The  condition  excites  a  burning  pain. 

Eczema. — The  skin  is  thickened  and  infiltrated ;  there  is 
marked  itching ;  the  redness  shades  off  gradually ;  and  there 
is  no  fever. 

Erysipelas. — The  part  is  considerably  swollen ;  the  redness 
and  swelling  terminate  in  an  abrupt  ridge  and  the  tempera- 
ture is  high. 

Acne  Rosacea. — This  is  a  chronic  disease;  the  redness 
appears  on  the  face  and  is  associated  with  acne  lesions  and 
dilated  capillaries. 

Vesicles. — A  vesicle  is  a  small  elevation  of  the  skin 
containing  serous  fluid,  and  varying  in  size  from  a  pinhead 
to  a  split-pea.  Vesicles  are  observed  in  the  following  con- 
ditions : 

Sudamen. — This  consists  of  an  eruption  of  minute  vesicles 
that  result  from  the  imprisonment  of  sweat  in  the  layers  of 
the  skin.  It  is  usually  associated  with  free  perspiration ;  the 
vesicles  are  translucent,  lack  inflammatory  characteristics, 
and  show  no  tendency  to  rupture. 

Herpes. — The  vesicles  appear  in  groups  or  clusters ;  they 
are  mounted  on  an  inflammatory  base ;  they  show  no  ten- 
dency to  rupture  ;  they  are  frequently  associated  with  burning 
or  neuralgic  pains  ;  and  they  are  distributed  along  the  line 
of  the  nerve-trunks. 

Dermatitis  Venenata. — A  vesicular  eruption  may  result 
from  contact  with  poisonous  plants,  such  as  the  poison-ivy 
or  poison-oak.  The  eruption  generally  appears  on  the  ex- 
posed parts — face  or  hands  ;  the  part  is  red  and  swollen  and 
there  is  intense  itching. 

Dermatitis  Herpetiformis. — The  vesicles  are  very  irregular 
in  shape ;  they  appear  in  clusters ;  they  are  very  tense ;  they 
show  no  tendency  to  rupture  ;  they  are  frequently  associated 
with  other  lesions — papules,  pustules,  and  bullae ;  they  excite 


CUTANEOUS  ERUPTIONS.  4/3 

intense  itching ;  and  they  appear  in  crops  over  a  period  of 
weeks  or  months. 

Impetigo  Contagiosa. — The  eruption  consists  of  small  vesi- 
cles that  subsequently  enlarge  until  they  reach  the  size  of 
blebs ;  the  vesicles  appear  in  crops ;  are  commonly  discrete ; 
are  flat  and  umbilicated ;  are  filled  with  a  straw-colored 
fluid ;  they  show  no  tendency  to  break,  but  dry  up  and  form 
thin  yellow  crusts,  and  they  excite  but  little  itching.  The 
disease  is  contagious  and  auto-inoculable ;  occurs  especially 
in  children ;  and  lasts  from  one  to  two  weeks. 

Vesicular  Eczema. — The  vesicles  are  quite  small  and  are 
aggregated  in  patches  ;  the  intervening  skin  is  red  and  thick- 
ened ;  the  vesicles  tend  to  break  and  pour  forth  a  serous 
fluid  that  keeps  the  part  moist ;  and  the  eruption  is  asso- 
ciated with  intense  itching. 

Miliaria,  or  Heat-rash. — This  may  appear  as  an  eruption  of 
minute  vesicles;  they  are  always  discrete;  they  are  sur- 
rounded by  red  areolae  ;  they  usually  appear  on  the  trunk ; 
they  are  generally  associated  with  pin-head  papules  ;  they 
show  no  tendency  to  rupture ;  and  they  excite  a  little  burn- 
ing and  itching. 

Scabies. — In  this  affection  the  vesicles  are  small ;  they  are 
usually  associated  with  pustules  and  burrows ;  they  excite 
intense  itching ;  and  they  are  usually  found  on  the  hands, 
forearms,  in  the  axillae,  under  the  mammae,  and  on  the  inner 
aspects  of  the  thighs. 

Blebs,  or  Bullae. — A  bleb,  or  bulla,  is  a  circumscribed 
elevation  of  the  skin  containing  serous  fluid,  and  varying  in 
size  from  a  pea  to  an  ^%^.  Blebs  are  observed  in  the  follow- 
ing conditions  : 

Impetigo  Contagiosa. — The  blebs  are  flat  and  umbilicated  ; 
they  contain  a  straw-colored  fluid ;  they  appear  in  crops ; 
they  are  commonly  discrete ;  they  show  no  tendency  to 
break,  but  dry  up  and  form  thin  yellow  crusts  ;  and  they 
excite  but  little  itching.  The  disease  is  contagious  and  auto- 
inoculable;  occurs  especially  in  children;  and  lasts  from  one 
to  two  weeks. 

Dermatitis  Herpetiformis. — The  bullae  are  frequently  asso- 
ciated with  papules,  vesicles,  and  pustules ;  they  are  sur- 


474   DISEASES   OF  THE   SKIN  AND   ITS  APPENDAGES. 

rounded  by  inflamed  skin ;  they  appear  in  clusters  ;  they 
show  no  tendency  to  break,  but  dry  up  and  leave  yellowish- 
brown  crusts  ;  and  they  excite  considerable  itching. 

Pemphigus. — The  bullae  appear  in  crops ;  excite  but  little 
itching ;  they  lack  an  inflammatory  areola ;  and,  as  a  rule, 
they  dry  up,  and  leave  behind  a  thin  pellicle.  The  disease 
is  generally  chronic. 

Syphilis. — The  bullous  syphilid  is  observed  in  hereditary 
syphilis  and  very  late  in  the  acquired  disease.  The  contents 
of  the  bullae  soon  become  pustular ;  the  blebs  diy  up,  and 
form  dark-green,  cone-shaped,  stratified  crusts,  which  become 
detached  and  leave  discharging  ulcers.  The  history  and  the 
other  evidences  of  syphilis  will  aid  in  the  diagnosis. 

Pustules. — A  pustule  is  a  small  circumscribed  elevation 
of  the  skin  containing  pus.  Pustules  are  observed  in  the 
following  diseases : 

Eczema  Pustulosum. — The  pustules  are  small ;  are  aggre- 
gated in  a  patch  ;  are  generally  associated  with  minute  vesi- 
cles ;  the  intervening  skin  is  red  and  thickened ;  and  there 
are  marked  burning  and  itching. 

Acne  Vulgaris. — The  pustules  are  usually  confined  to  the 
face,  back,  and  shoulders  ;  they  have  their  origin  in  the 
sebaceous  follicles ;  they  are  generally  associated  with  papules 
and  comedones ;  and  they  excite  no  itching. 

Dermatitis  Herpetiformis. — The  pustules  are  frequently 
associated  with  papules  and  vesicles ;  they  are  surrounded 
by  inflamed  skin  ;  they  appear  in  clusters ;  and  they  excite 
considerable  itching. 

Impetigo  Contagiosa. — The  eruption  is  at  first  vesicular, 
but  it  soon  becomes  pustular ;  the  pustules  vary  in  size  from 
a  pea  to  a  large  marble  ;  they  are  flat  and  umbilicated  ;  they 
appear  in  crops ;  they  are  commonly  discrete ;  they  show 
no  tendency  to  break,  but  dry  up  and  form  thin  yellow 
crusts ;  and  they  excite  but  little  itching.  The  disease  is 
contagious  and  auto-inoculable ;  occurs  especially  in  chil- 
dren ;  and  lasts  from  one  to  two  weeks. 

Varicella,  or  Chicken-pox. — The  pustules  result  from  vesi- 
cles ;  they  appear  especially  on  the  trunk ;  they  are  small 
and  are  not  umbilicated  and  they  excite  but  little  itching. 


CUTANEOUS  ERUPTIONS. 


47  S 


There  is  some  fever.  The  disease  lasts  but  three  or  four 
days. 

Ecthyma. — This  disease  is  observed  especially  in  poorly 
nourished  adults.  The  pustules  vary  in  size  frorn  a  pea  to  a 
cherry ;  they  are  few  in  number ;  they  are  mounted  on  an 
inflammatory  base,  and  are  surrounded  by  a  distinct  inflam- 
matory areola ;  they  excite  but  little  itching ;  they  seldom 
break,  but  dry  up  and  form  brownish  crusts. 

Smallpox. — In  this  disease  shot-like  papules  and  umbili- 
cated  vesicles  precede  or  are  associated  with  the  pustules. 
The  latter  are  small,  surrounded  by  a  red  areola,  and  usually 
excite  some  itching.  The  high  fever  and  history  of  con- 
tagion will  assist  in  making  the  diagnosis. 

Syphilis. — The  pustules  are  frequently  associated  with 
other  lesions  ;  they  are  often  mounted  on  a  copper-colored 
inflammatory  base ;  they  excite  no  itching ;  and  they  are 
usually  associated  with  the  history  and  the  other  evidences 
of  syphilis. 

Scabies. — The  pustules  are  small  and  usually  associated 
with  papules,  vesicles,  and  burrows ;  they  are  especially 
observed  on  the  hands,  forearms,  in  the  axillae,  under  the 
mammae,  and  on  the  inner  aspects  of  the  thighs,  and  they 
excite  considerable  itching.  There  is  often  a  history  of  con- 
tagion. 

Papules. — A  papule  is  a  circum.scribed  solid  elevation  of 
the  skin  varying  in  size  from  a  pin-head  to  a  pea.  Papules 
are  observed  in  the  following  conditions  : 

Erythema  Multiforme. — The  papules  are  often  associated 
\Yith  macules  and  tubercles ;  they  are  flat,  and  are  of  a 
bright-red  or  purple  color;  they  appear  especially  on  the 
extremities ;  and  they  show  no  tendency  to  suppurate,  but 
gradually  disappear  in  the  course  of  two  or  three  weeks  ; 
they  excite  no  itching,  but  they  are  often  associated  with 
prostration  and  rheumatic  pains. 

After  the  Use  of  Certain  Drugs. — Bromids,  iodids,  copaiba, 
cubebs,  and  tar  may  produce  a  papular  eruption.  The  his- 
tory will  aid  in  the  diagnosis. 

Eczema  Papulosum. — The  papules  are  very  small,  closely 


476  DISEASES   OF   THE   SKIN  AND   ITS  APPENDAGES. 

aggregated,  and  often  associated  with  vesicles  and  pustules ; 
the  skin  is  thickened ;  and  there  is  intense  itching. 

Miliaria,  or  Prickly  Heat. — The  papules  are  very  small; 
they  are  very  often  associated  with  minute  vesicles ;  they 
always  remain  discrete ;  they  appear  especially  on  the  trunk ; 
and  they  excite  a  little  burning  and  itching. 

Acne  Vulgaris. — The  papules  are  usually  confined  to  the 
face,  back,  and  shoulders ;  they  are  generally  associated  with 
pustules  and  comedones;  they  involve  the  sebaceous  fol- 
licles ;  and  they  do  not  excite  subjective  symptoms. 

Scabies. — The  papules  are  small  and  are  usually  associated 
with  pustules,  vesicles,  and  burrows ;  they  are  especially  ob- 
served on  the  hands,  forearms,  in  the  axillae,  under  the 
mammae,  and  on  the  inner  aspects  of  the  thighs ;  and  they 
excite  considerable  itching.  There  is  often  a  history  of  con- 
tagion. 

Syphilis. — The  papules  are  dark  in  color ;  they  are  widely 
distributed,  being  especially  marked  on  the  trunk  and  flexor 
surfaces  of  the  extremities  ;  they  are  usually  associated  with 
pustules ;  and  they  excite  no  itching.  The  history  and  the 
accompanying  evidences  of  syphilis  will  aid  materially  in 
establishing  the  diagnosis. 

Smallpox. — The  papules  are  hard  and  have  a  shot-like 
feel ;  they  soon  terminate  in  umbilicated  vesicles  ;  they  excite 
some  itching,  and  they  are  associated  with  high  fever,  pain 
in  the  back,  and  often  a  history  of  contagion. 

Measles. — The  papules  are  small,  and  run  together  to 
form  crescentic-shaped  patches  ;  and  they  are  associated  with 
moderate  fever,  swollen  cervical  glands,  coryza,  conjunctivitis, 
and  bronchitis.     There  is  often  a  history  of  contagion. 

Tubercles. — Tubercles  are  large,  circumscribed,  solid 
elevations  of  the  skin  varying  in  size  from  that  of  a  large 
pea  to  that  of  a  walnut.  They  are  observed  in  the  following 
conditions  : 

Erythema  Nodosum. — The  tubercles  are  large ;  they  usually 
appear  on  the  extremities ;  they  are  reddish-purple  in  color ; 
they  never  suppurate ;  and  they  are  associated  with  malaise, 
fever,  and  rheumatic  pains. 

Erythema  Multiforme. — The  tubercles  are  generally  asso- 


CUTANEOUS  ERUrriONS.  ^yy 

dated  with  macules  and  papules ;  they  are  flat,  and  are  of  a 
bright-red  or  purple  color;  they  appear  especially  on  the 
extremities,  and  they  show  no  tendency  to  suppurate,  but 
gradually  disappear  in  the  course  of  two  or  three  weeks. 
They  excite  no  itching,  but  are  often  associated  with  pros- 
tration and  rheumatic  pains.  The  disease  is  probably  allied 
to  erythema  nodosum. 

Lupus  Vulgaris. — This  may  begin  as  a  papule  or  tubercle. 
It  is  especially  observed  on  the  face.  The  tubercles  are  of  a 
pale-red  color  and  are  quite  soft  to  the  touch.  As  a  rule, 
they  slowly  break  down  and  form  shallow  ulcers  with  soft 
red  margins.  The  ulcers  are  painless  and  secrete  but  little 
material.  They  may  invade  all  the  soft  structures,  but  the 
bones  escape. 

Syphilis. — The  tubercular  syphilid  manifests  itself  as  dark- 
red  tubercles.  There  are  seldom  more  than  three  or  four, 
and  they  generally  appear  on  the  face  and  extremities. 
They  are  very  firm  and  often  break  down,  forming  deep, 
punched-out  ulcers  that  secrete  an  abundant  purulent  ma- 
terial. 

Tinea  Sycosis,  or  Barber's  Itch. — The  tubercles  appear  on 
the  hairy  parts  of  the  face  and  involve  the  hair-follicles. 
Suppuration  soon  begins  in  the  center  of  the  tubercles,  and 
the  hairs  become  dry,  brittle,  and  loose.  The  microscope 
will  reveal  the  trichophyton. 

Leprosy. — One  form  of  leprosy  manifests  itself  as  tuber- 
cles. The  latter  are  of  a  pale-red  or  yellow  color,  and  un- 
dergo slow  absorption  or  ulceration.  There  is  usually  more 
or  less  anesthesia  in  the  parts  affected. 

WhealSy  or  Pomphi. — Wheals  are  evanescent  eleva- 
tions of  the  skin,  generally  more  or  less  round,  and  often 
white  in  the  center  and  pale-red  at  the  periphery.  They 
excite  considerable  itching.  They  are  observed  in  the  fol- 
lowing conditions : 

Urticaria. — The  wheals  appear  in  crops ;  they  are  of  very 
short  duration ;  they  may  appear  on  any  part  of  the  body ; 
and  they  excite  intense  itching. 

Erythema  multiforme,  peliosis  rheumatica  (Schonlein's  dis- 
ease), and  certain  insects,  Hke  mosquitos,  also  produce  wheals. 


478    DISEASES   OF  THE  SKIN  AND  ITS  APPENDAGES, 

Crusts. — Crusts  consist  in  dried  exudation,  and  may  be 
red,  yellow,  brown,  or  green  in  color.  They  are  marked  in 
the  following  diseases : 

Eczema. — The  crusts  are  generally  associated  with  pustules 
and  vesicles  ;  the  surrounding  skin  is  red  and  thickened  ;  and 
there  is  considerable  itching. 

Seborrhea. — Crusts  of  seborrhea  are  generally  observed  on 
the  scalp.  Itching  is  absent,  and  there  are  no  evidences  of 
inflammation. 

Syphilis. — The  crusts  are  thick  ;  they  are  of  a  dark-brown 
or  green  color ;  and  they  are  often  associated  with  ulcers 
that  freely  discharge.  The  history  and  other  evidences  of 
syphilis  will  aid  in  the  diagnosis. 

Impetigo. — The  crusts  are  thin  and  yellow,  and  they  are 
associated  with  blebs  that  appear  in  crops. 

Favus. — The  crusts  generally  appear  on  the  scalp ;  they 
are  yellow,  brittle,  and  cup-shaped ;  they  are  usually  per- 
forated by  a  hair,  and  have  a  peculiar  musty  odor. 

Tinea  Tonsurans,  or  Ringworm  of  the  Scalp. — In  neglected 
cases  this  affection  may  be  associated  with  crusting.  It  is 
observed  only  in  children.  The  grayish  scales,  the  dry, 
brittle,  and  broken  hairs  projecting  through  the  crusts,  the 
alopecia,  and  the  detection  of  the  trichophyton  are  the  diag- 
nostic features. 

Scales. — Scales  are  dry  exfoliations  from  the  upper- 
layers  of  the  skin.  They  are  observed  in  the  following 
diseases : 

Squamous  Eczema. — The  scales  are  usually  associated  with 
papules ;  the  underlying  skin  is  red  and  thickened,  and  there 
is  often  marked  itching. 

Seborrhoea  Sicca. — The  scales  are  greasy,  and  the  under- 
lying skin  shows  no  evidence  of  inflammation.  The  seba- 
ceous follicles  are  often  dilated. 

Psoriasis. — The  scales  are  dry,  and  are  of  a  pearly-white 
color ;  they  are  associated  with  circumscribed,  sharply  de- 
fined, elevated,  inflammatory  patches.  The  extensor  sur- 
faces are  especially  involved.     There  is  little  or  no  itching. 

Ichthyosis.  —  This  affection  begins  in  early  life.  The 
scales  are  dry,  and  are  especially  marked  on  the  extensor 


CUTANEOUS  ERUPTIONS.  479 

surfaces.  Itching  is  absent,  and  there  is  no  evidence  of 
inflammation. 

Syphilis. — The  scales  are  dry  and  are  of  a  grayish  color ; 
they  are  usually  associated  with  papules  ;  and  they  are  espe- 
cially marked  on  the  palms  and  soles.  There  is  no  itching. 
The  history  and  other  evidences  of  syphilis  will  assist  in  the 
diagnosis. 

Pityriasis  Rosea. — The  scales  are  found  especially  on  the 
trunk,  and  are  associated  with  small,  rose-red  macules. 
There  is  no  itching.  The  disease  runs  an  acute  course  of  a 
few  weeks'  duration. 

Ringworm. — The  scales  are  dry  and  scant ;  they  are  asso- 
ciated with  circumscribed  red  patches  that  tend  to  disappear 
in  the  center.  There  is  often  marked  itching.  Microscopic 
examination  reveals  the  trichophyton. 

Ulcers. — Ulcers  are  observed  especially  in  the  following 
diseases  : 

Syphilis. — The  ulcers  are  deep ;  they  have  a  punched-out 
appearance ;  they  secrete  an  abundant  offensive  material  ; 
they  often  involve  the  bone ;  they  extend  rapidly  ;  they  are 
not  painful,  and  the  imperfect  cicatrix  which  they  produce 
is  soft.  The  history  and  other  evidences  of  syphilis  will  aid 
in  the  diagnosis. 

Epithelioma. — This  appears  in  late  life  ;  there  is  usually  a 
single  center  of  ulceration  ;  the  ulcer  is  irregular  in  shape ; 
the  edges  are  thickened  and  infiltrated ;  the  secretion  is 
scanty  and  bloody ;  the  progress  is  somewhat  slow,  and 
there  is  often  pain. 

Lupus  Vulgaris. — This  generally  appears  in  early  life; 
there  are  often  several  centers  of  ulceration ;  the  ulcers  are 
usually  superficial ;  the  edges  are  not  thickened  ;  the  prog- 
ress is  extremely  slow  ;  the  bones  are  never  involved  ;  there 
is  very  little  secretion,  and  soft  papules  often  develop  in  the 
cicatrix,  which  is  firm  and  contracted. 

Simple  ulcers  may  result  from  traumatism,  the  application 
of  caustics,  or  the  action  of  intense  heat  or  cold.  Ulcers  are 
frequently  observed  on  the  legs  of  old  people  in  association 
with  varicose  veins.  Simple  ulcers  may  be  recognized  by 
the  history,  location,  appearance,  and  absence  of  other  causes. 


48o  DISEASES   OF   THE   SKIN  AND   ITS  APPENDAGES. 

Perforating  Ulcer  of  the  Foot. — This  term  is  applied  to  a 
deep-seated  ulcer  appearing  on  the  sole  of  the  foot  and  most 
frequently  observed  in  locomotor  ataxia.  It  usually  begins 
as  a  corn  in  the  neighborhood  of  the  great  toe,  and  is  gen- 
erally associated  with  anesthesia  of  the  sole  of  the  foot. 

Decubitus. — This  term  is  applied  to  the  bed-sores  that 
form  after  the  occurrence  of  grave  cerebral  or  spinal  lesions. 
They  are  generally  observed  on  parts  that  are  subjected  to 
pressure,  as  the  sacrum,  buttocks,  calves,  and  heels,  and  are 
preceded  by  erythema  and  vesication. 


DISEASES  OF  THE  SWEAT-GLANDS. 

ANIDROSIS. 

Definition. — A  deficiency  of  sweat. 

Htiolog"y. — It  may  be  a  symptom  of  some  general  dis- 
ease, like  diabetes  or  Bright's  disease ;  it  may  be  an  asso- 
ciated condition  in  certain  cutaneous  diseases,  such  as 
ichthyosis  or  psoriasis  ;  and  it  may  develop  without  obvious 
exciting  cause  as  a  result  of  disturbed  innervation. 

Treatment. — Remedies  should  be  directed  to  the  pri- 
mary disease. 

HYPERIDROSIS. 

Definition. — Excessive  sweating. 

etiology. — As  a  general  condition  it  is  often  observed 
in  phthisis  and  in  other  diseases  characterized  by  marked 
debility.  Local  hyperidrosis  is  most  frequently  observed  in 
the  hands,  feet,  and  axillae,  and  probably  results  from  some 
derangement  of  the  sympathetic  nervous-  system.  Unilateral 
sweating  of  the  face  may  indicate  an  aneurysm  or  tumor 
pressing  on  the  cervical  sympathetic. 

Symptoms. — The  primary  symptom  is  excessive  sweat- 
ing, and  this  often  leads  to  intertrigo  or  eczema.  Bromi- 
drosis  is  often  associated  with  the  hyperidrosis. 


BR  OMIDR  OSIS—  CHR  OMIDR  OS  IS.  481 

Prognosis. — Guarded.  In  many  cases  the  condition  is 
very  obstinate. 

Treatment. — Frequently  there  is  an  evident  impairment 
of  the  general  health  that  will  require  appropriate  treatment. 
Internally,  one  of  the  following  remedies  may  be  employed 
to  diminish  the  amount  of  sweat  :  belladonna,  picrotoxin, 
agaricin,  or  ergot. 

Local  Treatment. — Dusting-powders  of  starch,  talc,  or 
lycopodium  with  tannoform  or  boric  or  salicyHc  acid ;  or 
lotions  containing  sulphate  of  zinc,  tannic  acid,  or  alum  are 
often  very  useful. 

R.     Pulveris  acidi  salicylic! 

Pulveris  zinci  carbonatis  prsecipitati 

Pulveris  magnesii  usta; aa  ^iv 

Pulveris  amyli gxv 

Pulveris  talci 3^x- — M- 

SiG. — Dusting-powder.  (Hardaway.) 

In  hyperidrosis  of  the  feet  the  method  suggested  by 
Hebra  is  often  very  efficient.  The  feet  should  be  washed, 
thoroughly  dried,  and  then  carefully  enveloped  in  strips  of 
muslin  that  have  been  spread  with  diachylon  ointment.  The 
application  should  be  made  twice  daily.  In  the  dressing  no 
water  should  be  employed,  but  the  feet  must  be  carefully 
wiped  and  then  dusted  with  starch  or  lycopodium  before  the 
ointment  is  reapplied.  The  treatment  should  be  continued 
for  from  one  to  two  weeks,  after  which  the  feet  may  be 
washed  and  the  dusting-powder  alone  used. 

BROMIDROSIS* 

(Osmidrosis.) 

Definition. — A  functional  affection  characterized  by  the 
excretion  of  sweat  that  has  a  fetid  odor. 

Symptoms. — It  is  generally  local  and  often  confined  to 
the  feet ;  it  is  frequently  associated  with  hyperidrosis. 

Treatment. — Same  as  hyperidrosis. 

CHROMIDROSIS^ 

Definition. — A  functional  affection  characterized  by  the 
secretion  of  colored  sweat. 

31 


482    DISEASES   OF  THE   SKIN  AND  ITS  APPENDAGES. 

Symptoms. — The  parts  most  frequently  affected  are  the 
face  and  trunk  ;  the  most  common  colors  are  red  and  yellow. 
It  is  often  associated  with  hyperidrosis. 

SUDAMEN. 

Definition. — A  cutaneous  affection,  characterized  by  the 
eruption  of  minute  vesicles,  resulting  from  the  retention  of 
sweat  in  the  upper  layers  of  the  skin. 

etiology. — It  is  often  observed  in  health  in  persons  who 
perspire  freely.  It  is  frequently  noted  in  febrile  diseases 
that  are  associated  with  sweating,  like  pneumonia  and 
typhoid  fever. 

Symptoms. — Minute,  irregular,  translucent  vesicles  ap- 
pear on  the  surface.  They  are  not  surrounded  by  an  in- 
flammatory areola.  They  do  not  rupture,  but  dry  up  and 
are  followed  by  slight  desquamation. 

Treatment. — The  affection  has  little  significance,  and 
treatment  is  rarely  required. 


FUNCTIONAL  DISEASES  OF  THE  SEBACEOUS 

GLANDS. 

SEBORRHEA. 

(Steorrhea.) 

Definition. — A  functional  affection,  characterized  by  ex- 
cessive secretion  of  sebaceous  material,  which  may  be 
normal  or  perverted. 

Etiology. — In  many  cases  the  cause  is  not  apparent. 
Often  the  disease  is  associated  with  impairment  of  the  gen- 
eral health.     By  some  it  is  regarded  as  of  parasitic  origin. 

Varieties. — Seborrhoea  sicca  and  seborrhoea  oleosa. 

Seborrhoea  Sicca. — This  form  is  most  frequently  observed 
on  the  scalp,  and  constitutes  what  is  popularly  termed  dan- 
druff.    Examination  reveals   an  incrustation   composed    of 


SEBORRHEA.  483 

thin,  yellowish-gray,  greasy  scales.  In  uncomplicated  cases 
the  skin  is  pale,  but  from  irritation  it  may  subsequently  be- 
come hyperemic  or  inflamed.  When  allowed  to  continue, 
the  nutrition  of  the  hair  is  interfered  with  and  baldness 
results. 

On  the  body  seborrhoea  sicca  appears  as  yellowish-gray, 
slightly  elevated  patches  covered  with  greasy  scales.  The 
outlets  of  the  follicles  are  often  dilated.  There  is  generally 
more  or  less  redness  of  the  skin  from  hyperemia  {seborrheal 
eczema). 

Seborrhoea  Oleosa. — This  form  is  most  commonly  observed 
on  the  face,  particularly  about  the  nose,  which  is  habitually 
bathed  in  an  oleaginous  material  that  has  exuded  from  the 
sebaceous  follicles.  From  irritation  the  parts  are  often  red. 
The  condition  is  frequently  associated  with  seborrhoea  sicca, 
comedo,  and  acne. 

Diagnosis. — Eczema. — In  this  disease  the  skin  is  red  and 
thickened ;  there  is  marked  itching ;  and  the  scales  are  not 
greasy. 

Psoriasis. — In  this  disease  the  scales  are  dry  and  pearly 
and  there  are  evidences  of  inflammation. 

Prognosis. — Favorable  under  prolonged  and  judicious 
treatment. 

Treatment. — The  general  health  may  be  impaired ;  hence 
tonics,  like  iron,  strychnin,  and  cod-liver  oil,  are  often  indi- 
cated. The  gastro-intestinal  tract  will  often  require  especial 
attention.  Constipation  should  be  relieved  by  diet,  enemas, 
or  mild  laxatives. 

Local  Treatment. — Crusts  should  be  removed  by  applica- 
tions of  oil,  followed  by  shampooing  with  alcohol  and  green 
soap.  When  the  scalp  is  thoroughly  clean,  one  of  the  fol- 
lowing remedies  may  be  applied  :  sulphur,  mercury,  saHcylic 
acid,  carbolic  acid,  or  resorcin. 

R.    Cerse  albse ,^ij 

Petrolati  liquid! f^ij 

Aquse  rosge ^S^^j 

Sodii  boratis gr.  x 

Sulphuris      ^ij.— M. 

Fiat  unguentum. 

SiG. — Apply  at  bedtime  for  several  nights,  then  shampoo. 


484   DISEASES   OF  THE   SKIN  AND  ITS  APPENDAGES. 

Or: 

R.     Resorcinolis 3^ 

Olei  ricini TtLxx 

Spiritus  myrciae 

Alcoholis      aa  f^iij.— M. 

SiG, — Fill  an  eye-dropper,  introduce  between  the  hairs,  and  sub- 
sequently rub  in  by  means  of  a  flannel  rag. 

Mild  cases  of  facial  seborrhea  often  yield  to  the  following 
ointment : 

R.    Hydrargyri  ammoniati gr.  xx-xxx 

Unguenti  aquae  rosse   .0    .....    •    ^j. — -M. 
SiG. — Apply  at  bedtime. 

COMEDO* 

Definition. — A  functional  disease  of  the  sebaceous  glands, 
characterized  by  the  retention  of  discolored  sebaceous  mate- 
rial in  the  distended  ducts  of  the  gland. 

i^tiology. — It  is  most  frequently  observed  in  young 
adults.  Debility,  gastro-intestinal  disorders,  anemia,  and 
lack  of  cleanliness  are  predisposing  factors. 

Pathology. — The  material  in  the  ducts  is  composed  of 
sebum,  altered  epithelium,  and  pigment  matter  that  is  prob- 
ably derived  from  without.  Microscopic  examination  of  the 
material  often  reveals  a  mite, — the  Demodex  folliculoriim, — 
but  its  presence  is  accidental  and  of  no  etiologic  significance. 
Comedo  is  generally  associated  with  seborrhea. 

Symptoms. — The  disease  is  characterized  by  an  aggrega- 
tion of  minute  black  or  yellowish  spots  that  correspond  to 
the  outlets  of  the  sebaceous  glands.  The  lesion  is  often 
slightly  elevated,  and  when  the  skin  is  squeezed,  a  white, 
filiform  mass  exudes,  to  which  the  term  "  flesh-worm  "  has 
been  popularly  applied.  The  parts  most  commonly  affected 
are  the  face,  back,  and  ears.  The  condition  frequently  ex- 
cites an  inflammation  of  the  follicles,  hence  it  is  often  asso- 
ciated with  acne. 

Prognosis. — Favorable  under  persistent  and  judicious 
treatment. 

Treatment. — Anemia,  dyspepsia,  and  constipation  must 
be  treated  by  a  careful  regulation  of  the  personal  hygiene 


MILIUM— STEA  TO  MA,  48  5 

and  by  the  use  of  appropriate  remedies.     Tonics,  like  iron, 
quinin,  cod-liver  oil,  and  strychnin,  are  often  indicated. 

Local  Treatment. — Large  plugs  may  be  pressed  out  by 
means  of  a  watch-key  or  a  special  instrument  for  the  pur- 
pose. Softening  and  removal  of  smaller  plugs  may  be 
hastened  by  the  application  of  cloths  wrung  out  in  very  hot 
water.  Kneading  and  the  application  of  alcohol  and  green 
soap  will  also  assist  in  their  expulsion.  Mercury  and  sulphur 
are  useful  remedies. 

]^.    Hydrargyri  chloridi  corrosivi      .    .    .    .    gr.  iv 

Alcoholis fjj 

Aquae  rosae q.  s.  ad  fjiv. — M. 

SiG. — Dab  on  twice  daily. 

MILIUM* 

(Grutum.) 

Definition. — An  affection  characterized  by  the  appear- 
ance of  small,  pearly,  non-inflammatory  elevations,  which 
result  from  the  accumulation  of  inspissated  sebum  in  ducts, 
the  outlets  of  which  have  been  occluded. 

Symptoms. — It  is  generally  observed  about  the  face, 
and  consists  of  a  collection  of  small,  round,  pearly  eleva- 
tions, which  vary  in  size  from  a  pin-head  to  a  millet  seed. 
The  contents  of  the  distended  duct  cannot  be  squeezed  out 
until  an  opening  is. made,  and  thus  it  differs  from  comedo. 
It  is  frequently  associated  with  comedo  and  acne. 

Treatment. — Mild  sulphur  ointments  are  sometimes 
useful.  In  obstinate  cases  the  lesions  should  be  punctured, 
the  contents  squeezed  out,  and  the  interior  touched  with 
tincture  of  iodin. 

STEATOMA* 

(Wen.) 

Definition.~A  steatoma,  or  wen,  is  a  cyst  resulting 
from  the  retention  of  secretion  in  a  sebaceous  gland. 

Symptoms. — One  or  more  rounded  or  oval  elevations, 
varying  in  size  from  a  pea  to  a  large  walnut,  slowly  appear 
on  the  scalp,  face,  or  back.     They  are  painless,  rather  soft, 


486   DISEASES   OF   THE   SKIN  AND   ITS  APPENDAGES. 

and  when  opened,  are  found  to  contain  a  yellowish-white, 
caseous  mass. 

Diagnosis. — Fatty  Tumors. — Fatty  tumors  are  rare  on 
the  scalp ;  they  are  frequently  lobulated  ;  they  have  a  doughy 
feel ;  and  are  not  so  movable  as  wens. 

Treatment. — The  sac  and  its  contents  should  be  care- 
fully dissected  out.  Simple  excision  and  evacuation  are 
always  followed  by  a  return  of  the  cyst. 


INFLAMMATORY  DISEASES   OF  THE  SKIN. 

ERYTHEMA  SIMPLEX. 

Definition.— Active  hyperemia  of  the  skin. 

etiology. — It  may  result  from  exposure  to  heat  or  cold ; 
from  traumatism  ;  or  from  the  application  of  some  irritating 
substance.  A  symptomatic  variety  is  frequently  observed  in 
gastric  irritation  and  systemic  diseases. 

Byttlptoms. — Diffuse  uniform  redness,  disappearing  on 
pressure,  and  without  thickening  or  elevation  of  the  skin. 
When  it  is  marked,  there  may  be  slight  burning. 

Treatment. — Sedative  lotions  or  dusting-powders  suffice. 

ERYTHEMA  INTERTRIGO. 

(Chafing.) 

Definition. — Hyperemia  induced  by  the  attrition  of  op- 
posing surfaces  of  the  skin. 

^tiology.^It  is  common  in  children  and  in  fat  subjects. 
It  is  especially  noted  where  there  are  friction  and  perspira- 
tion, as  under  pendulous  mammae,  between  the  upper  parts 
of  the  thighs,  and  around  the  genitalia. 

Symptoms. — It  is  characterized  by  diffuse  redness,  and 
often  by  heat  and  moisture.  It  excites  a  burning  sensation. 
When  the  cause  is  continued,  it  may  result  in  dermatitis. 

Treatment. — After  bathing  the  parts  with  a  lotion  of 
boric  acid,  the  following  dusting-powder  may  be  used : 


ERYTHEMA   MULTIFORME.  487 

R.    Pulveris  camphorse  .    .    , ^j 

Pulveiis  amyli 

Pulveris  zinci  oxidi aa  ^ss. 

ERYTHEMA  NODOSUM* 

(Dermatitis  Contusiformis.) 

Definition. — An  acute  inflammatory  disease,  character- 
ized by  crops  of  large,  bright-red  nodes  that,  in  the  process  of 
evolution,  assume  different  colors,  as  in  the  fading  of  a  bruise. 

^^tiology. — It  is  usually  seen  in  children.  It  is  fre- 
quently associated  with  rheumatic  and  digestive  disturbances. 

Symptoms. — There  is  a  sudden  eruption  of  bright-red 
nodes,  varying  in  size  from  a  pea  to  an  ^^^.  The  extremi- 
ties are  most  commonly  affected.  The  advent  is  marked  by 
malaise,  headache,  slight  fever,  and  rheumatoid  pains.  At 
first  the  lesions  resemble  boils,  but,  unlike  the  latter,  they  do 
not  suppurate,  but  gradually  turn  yellow,  blue,  and  green,  as 
a  bruise. 

Prognosis. — Favorable.     Duration,  a  few  weeks. 

Treatment. — Saline  laxatives  and  sodium  salicylate  are 
recommended.  Locally,  a  lotion  of  lead-water  and  laudanum 
makes  a  soothing  application. 

ERYTHEMA  MULTIFORME. 

Definition. — An  inflammatory  disease  characterized  by 
erythematous,  papular,  vesicular,  or  bullous  lesions. 

!^tiology. — It  is  more  common  in  women  than  in  men. 
It  is  apt  to  develop  in  the  spring  or  fall.  Rheumatism  and 
gastro-intestinal  disturbances  seem  to  predispose. 

Symptoms. — It  is  marked  by  an  eruption,  usually  on 
the  extremities,  of  the  following  lesions  :  macules,  papules, 
vesicles,  or  bullae.  The  lesions  may  aggregate  or  remain 
discrete ;  they  last  one  or  two  weeks  and  gradually  fade. 
There  is  little  or  no  itching.  In  some  cases  there  is  decided 
constitutional  disturbance,  manifested  by  malaise,  headache, 
slight  fever,  and  rheumatic  pains. 

Diagnosis.  —  Dermatitis  Herpetiformis.  —  The  marked 
itching,  the  greater  tendency  for  the  lesions  to  cluster,  and 


488    DISEASES   OF   THE   SKIN  AND   ITS  APPENDAGES. 

the  chronic  character  of  dermatitis  herpetiformis  will  usually 
prevent  an  error  in  diagnosis. 

Urticaria. — In  this  disease  the  individual  lesions  last  a  very 
short  time  and  are  associated  with  marked  itching. 

Prognosis. — Favorable.     Duration,  a  few  weeks. 

Treatment. — In  the  debilitated  iron  and  quinin  are  use- 
ful.. In  the  rheumatic,  the  salts  of  lithium  and  of  potassium 
may  be  employed.  Constipation  should  be  relieved  by 
saline  laxatives.  Locally,  lotions  of  boric  or  carbolic  acid 
followed  by  dusting-powders  exert  a  beneficial  effect. 

URTICARIA. 

(Hives;  Nettlerash.) 

Definition. — An  inflammatory  affection  characterized  by 
the  eruption  of  pale-red,  evanescent  wheals  that  are  asso- 
ciated with  severe  itching. 

iJ^tiology. — Gastro-intestinal  disturbances,  emotional  ex- 
citement, and  chronic  visceral  diseases  predispose.  In  some 
it  may  be  excited  by  certain  articles  of  food,  such  as  shell- 
fish, strawberries,  etc.  The  bites  of  certain  insects  produce 
the  disease,  such  as  mosquitos,  bedbugs,  and  caterpillars. 
Some  drugs  induce  urticaria  in  susceptible  people. 

Pathology. — The  disease  consists  in  a  vasomotor  spasm, 
followed  by  paresis  of  vessels  and  an  outpouring  of  serum. 

Symptoms. — There  is  a  sudden  general  eruption  of 
papules  or  wheals  that  is  associated  with  intense  itching. 
Each  lesion  lasts  a  few  hours  and  is  succeeded  by  new  ones 
in  other  places. 

Varieties. — Urticaria  Papulosa. — In  this  form  the  wheal 
is  followed  by  a  lingering  papule  that  is  attended  by  con- 
siderable itching.     It  is  most  commonly  observed  in  children. 

Urticaria  Hsemorrhagica. — The  lesions  are  infiltrated  with 
blood. 

Urticaria  Tuberosa  (Giant  Urticaria). — In  this  form  the 
wheals  may  reach  the  size  of  an  ^%%. 

Diagnosis. — Erythema  Multiforme  and  Erythema  Nodo- 
sum.— In  both  of  these  affections  the  lesions  last  much 
longer  and  are  free  from  itching. 


HERPES  SIMPLEX.  ^oC) 

Prognosis. — Favorable.  In  some  cases  it  tends  to  be- 
come chronic. 

Treatment. — The  cause  should  be  removed  when  possi- 
ble. In  gastric  irritation  bismuth  or  calomel  and  soda  are 
useful. 

When  there  is  constipation,  a  saline  laxative  may  prove 
very  efficient.  The  special  remedies  usually  recommended 
are  alkalis,  sodium  salicylate,  quinin,  potassium  bromld, 
and  atropin. 

Locally,  lotions  of  water  and  alcohol,  carbolic  acid,  boric 
acid,  or  hydrocyanic  acid  are  very  useful : 

JIJ.    Acidi  carbolici  . fi^j 

Glycerini f^ss 

Alcoholis f^j 

Aquae     .    .    .    .  ' q.  s.  ad  ff  viij. — M. 


URTICARIA  PIGMENTOSA. 

This  is  a  form  of  urticaria  observed  in  young  children. 
It  is  characterized  by  an  eruption  of  wheals  that  are  itchy 
and  persistent,  and  that  leave  behind  a  yellowish  or  brown- 
ish pigmentation.  The  disease  runs  a  chronic  course  of 
months  or  years. 

HERPES  SIMPLEX. 

(Fever-blisters.) 

Definition. — An  acute,  non-contagious  disease,  charac- 
terized by  groups  of  small  vesicles  mounted  on  inflamma- 
tory bases. 

Btiology. — Herpes  is  very  common  in  febrile  diseases, 
especially  pneumonia,  influenza,  malaria,  and  cerebrospinal 
meningitis.  Local  irritation  also  predisposes  to  it.  It  is  de- 
pendent upon  a  peripheral  toxic  neuritis. 

Symptoms. — One  or  more  clusters  of  small  vesicles 
appear,  usually  on  the  face  or  genitaha.  The  vesicles  are 
mounted  on  an  inflammatory  base,  contain  clear  fluid,  and 
show  no  tendency  to  rupture.  Soon  their  contents  become 
puriform,  dry  up,  and  form  reddish-brown  crusts  that  fall 


49^  DISEASES   OF  THE  SKIN  AND  ITS  APPENDAGES. 

off  in  a  few  days.  Burning  and  tingling  precede  and  accom- 
pany the  eruption. 

Varieties. — When  it  appears  on  the  face,  it  is  termed 
herpes  facialis  ;  on  the  genitals,  herpes  prog enitalis. 

Diagnosis. — Herpes  progenitalis  must  be  distinguished 
from  chancroid.  The  history,  the  superficial  character  of  the 
lesion,  the  burning  pain,  and  the  subsequent  course  will  in- 
dicate herpes. 

Treatment. — The  lesion  may  be  painted  with  flexible 
collodion,  or  the  following  lotion  employed : 

R.    Zinci  oxidi gr.  xv 

Glycerini .    Itt  xv 

Liquoris  plumbi  subacetatis  dilutus    .    .    ttt  ^ 
Liquoris  calcis f:^vi-fjj. — M. 

SiG. — Apply  locally.  (Tilbury  Fox.) 

HERPES  ZOSTER* 

(Zona;   Shingles.) 

Definition. — An  acute  inflammatory  disease,  character- 
ized by  groups  of  small  vesicles  mounted  on  inflammatory 
bases,  associated  with  neuralgic  pain,  and  following  the  dis- 
tribution of  certain  nerve-trunks. 

etiology. — The  disease  commonly  depends  upon  a 
peripheral  neuritis.  Injury,  exposure  to  cold,  and  damp 
clothes  predispose  to  it. 

Symptoms. — Clusters  of  vesicles  mounted  on  inflamma- 
tory bases  may  appear  on  any  part  of  the  body;  but  they 
are  most  frequently  observed  along  the  course  of  the  inter- 
costal nerves.  Only  one  side  is  affected.  Sharp  neuralgic 
pain  precedes  and  accompanies  the  eruption.  The  fluid  in 
the  vesicles  soon  becomes  turbid,  dries  up,  and  forms  yellow- 
brown  crusts  which  fall  off  in  a  few  days. 

Prognosis. — Favorable. 

Treatment. — Tonics  are  often  indicated.  Bulkley  rec- 
ommends phosphid  of  zinc  in  doses  of  -|^  of  a  grain  every 
three  hours.  Morphin  is  sometimes  required  for  the  relief 
of  pain.     Phenacetin,  however,  usually  suffices. 

Locally. — Sedative  applications  are  required  ;  the  best  are 
flexible  collodion  with  morphin,  or  a  solution  of  menthol  or 


HERPES  IRIS— ACNE.  49 1 

carbolic  acid,  followed  by  a  dusting-powder  of  oxid  of  zinc 
or  starch. 

K .    Morphinse  sulphatis gr.  ij 

Pulveris  amyli 

Pulveris  zinci  oxidi aa  ^ss. — M. 

HERPES  IRIS* 

Definition. — An  inflammatory  disease,  characterized  by 
groups  of  vesicles  arranged  in  concentric  rings  that  present 
a  somewhat  variegated  appearance, 

!^tiology. — The  causes  are  unknown.  The  disease  is 
rare. 

Symptoms. — One  or  more  rings  of  vesicles  successively 
appear  around  a  central  vesicle  or  papule.  The  different 
ages  of  the  rings  that  compose  the  patch  impart  to  the  latter 
a  variegated  appearance.  Burning  and  itching  are  often 
attendant  symptoms.  The  hands,  arms,  and  feet  are  the 
parts  most  frequently  affected.  The  lesions  appear  in  suc- 
cessive crops  over  a  period  of  several  weeks.  In  some  in- 
stances the  vesicles  are  quite  large  and  resemble  the  blebs 
of  pemphigus. 

Prognosis. — Favorable,  but  recurrent  attacks  are  com- 
mon. 

Treatment. — The  same  as  in  herpes  zoster. 

ACNE. 

(Acne  Vulgaris.) 

Definition. — An  inflammatory  disease  of  the  sebaceous 
glands,  characterized  by  papules  and  pustules  and  usually 
seated  on  the  face  or  back. 

Ktiology. — It  generally  develops  about  puberty.  Anemia, 
menstrual  disorders,  and  gastro-intestinal  disturbances  pre- 
dispose. Certain  drugs,  like  iodid  and  bromid  of  potassium 
and  copaiba,  may  induce  the  disease. 

Pathology. — Acne  lesions  result  from  the  irritation  ex- 
cited by  retained  sebaceous  matter,  hence  the  papules  and 
pustules  are  commonly  associated  with  blackheads,  or  come- 
dones. 


492   DISEASES   OF  THE   SKIN  AND   ITS  APPENDAGES. 

Symptoms. — An  aggregation  of  small  papules,  pustules, 
and  comedones  about  the  face,  chest,  and  shoulders.  Pus- 
tules or  papules  predominate  according  as  the  disease  is 
acute  or  chronic.  New  lesions  develop  as  the  old  disappear, 
so  that  the  disease  usually  runs  a  protracted  course.  Sub- 
jective phenomena  are  absent. 

Varieties. — Acne  Papulosa. — In  this  form  the  lesion 
reaches  the  papular  stage  and  advances  no  further. 

Acne  Pustulosa. — In  this  variety  the  papules  develop  into 
pustules. 

Acne  Indurata. — The  inflammation  is  deeply  seated,  the 
base  of  the  papule  or  pustule  is  firm,  and  the  lesion  is  slug- 
gish. 

Acne  Atrophica. — In  this  form  the  lesions  are  followed  by 
small  scars  or  pits. 

Acne  Hypertrophica. — In  this  form  there  is  an  overgrowth 
of  connective  tissue  and  the  skin  becomes  thickened. 

Diagnosis. — The  distribution,  the  chronic  character  of 
the  affection,  the  involvement  of  the  sebaceous  glands,  and 
the  association  with  comedones  are  the  diagnostic  features 
which  separate  acne  from  all  other  affections. 

Prognosis. — Curable  under  persistent  treatment. 

Treatment. — The  general  health  must  be  improved. 
The  diet  should  be  nutritious,  but  easily  assimilable ;  rich 
food  must  be  prohibited.  Constipation  should  be  relieved 
by  mild  laxatives.  In  the  anemic  and  debilitated,  iron, 
quinin,  strychnin,  and  cod-liver  oil  are  useful  remedies. 
The  special  drugs  which  have  been  recommended  are  arsenic, 
sulphur,  ergot,  and  calx  sulphurata.  Arsenic  is  best  suited 
to  the  sluggish  indurated  forms;  and  calx  sulphurata  (j^q-  to 
\  grain  four  times  daily)  to  the  pustular  variety. 

Local  Treatment. — In  the  acute  form  mild  applications 
should  be  employed,  like  the  following  calamin  lotion : 

5t.    Pulveris  zinci  oxidi ^lij 

Pulveris  calaminje    .........    ^ij 

Glycerin! .  iT^] 

Aquse  calcis f^vj. — M. 

In  chronic  cases  the  sebaceous  plugs  should  be  removed 
by  a  watch-key  and  the  pustules  incised.     Thorough  wash- 


ACNE   ROSACEA.  49S 

ing  with  very  hot  water  and  green  soap  is  also  advisable. 
The  best  local  remedies  are  sulphur,  mercury,  and  resorcin. 

R.    Calcis |ss 

Sulphuris  sublimati %] 

Aquge f5x.— M. 

Boil  together  with  constant  stirring  until  the  mixture  measures 

six  ounces  and  then  filter. 
SiG. — Apply  at  first  well  diluted    and   gradually  increase    the 
strength.  (Vleminckx.) 

Or: 

R.    Sulphuris  praecipitatis .^j 

Unguenti  aquce  rosae 

Petrolati  liquid!   .    .    .    .' aa  ^iv.— M. 

SiG.— Apply  night  and  morning.  (Van  Harlingen.) 

Or: 

R .    Hydrargyri  ammoniati    .......    gr.  xx-xl 

Unguenti  aquae  rosse ^j- — M. 

SiG. — Use  night  and  morning. 

Or : 

R.    Hydrargyri  chloridi  corrosivi      .    .    .    .    gr.  ss-ij 
Tincturae  benzoini  compositre     ....  f^j 
Emulsi  amygdalae  amarae    ......  f^iv. — M. 

SiG. — Use  locally. 

ACNE  ROSACEA. 

Definition. — A  chronic  affection,  usually  located  on  the 
face  in  the  region  of  the  nose,  and  characterized  by  marked 
hyperemia,  dilatation  of  the  vessels,  overgrowth  of  tissue, 
and  acne  lesions. 

Btiology. — Anemia,  menstrual  disorders,  gastric  distur- 
bances, exposure  to  extremes  of  temperature,  and  intem- 
perance are  the  usual  predisposing  causes. 

Symptoms. — The  affected  area  is  of  a  deep-red  color; 
the  vessels  are  dilated ;  the  skin  is  thickened  and  lumpy, 
and  acne  lesions  coexist.  In  advanced  cases  the  nose  may 
become  extremely  large  and  lobulated  (rhinophyma). 

Subjective  phenomena  are  generally  absent. 

Diagnosis. — Lupus  Vulgaris. — In  this  disease  there  are 
soft,  pale-red  papules,  ulceration,  cicatrization,  and  no  en- 
largement of  the  blood-vessels. 

Prognosis. — Unless  the  hypertrophy  is  marked,  the  dis- 
ease is  curable  under  protracted  treatment. 


494  DISEASES   OF   THE   SKIN  AND  ITS  APPENDAGES. 

Treatment. — The  general  treatment  is  the  same  as  in 
acne  vulgaris. 

Local  Ti^eatinent. — Sulphur  and  mercury  are  the  most 
reliable  remedies.  Vleminckx's  solution  is  very  useful  (see 
p.  491).  Dilated  vessels  should  be  destroyed  by  electrolysis. 
Large  hypertrophies  may  be  removed  by  the  knife. 

FURUNCULUS. 

(Boil.) 

Definition. — An  acute  circumscribed  inflammation  of  a 
sebaceous  gland  or  hair-follicle,  usually  terminating  in  sup- 
puration. 

;^tiology. — Single  boils  are  generally  due  to  local  irrita- 
tion. Their  appearance  in  crops  (furunculosis)  is  mainly 
indicative  of  impaired  health.  The  entrance  of  pus  cocci 
into  the  skin  is  always  essential  to  their  production. 

Diagnosis.  —  Furuncles  must  be  distinguished  from  car- 
buncles ;  the  latter  are  single,  large,  flattened  at  their  sum- 
mits, and  have  multiple  openings. 

Treatment. — In  furunculosis  the  cause  should  be  searched 
for  and,  if  possible,  removed.  Tonics  like  iron,  quinin,  cod- 
liver  oil,  and  hypophosphites  are  often  very  useful.  Calx 
sulphurata  (-5^-g-  grain  thrice  daily  after  meals)  sometimes 
proves  serviceable.  A  solution  of  boric  acid  or  of  corrosive 
sublimate  may  be  applied  locally.  The  following  paste  will 
sometimes  abort  them  : 

R.    Tchthyol gr-  x 

Unguenti  hydrargyri 

Extract!  belladonnse aa  '^]. — M. 

SiG. — Apply  locally  and  make  pressure  with  strips  oi  adhesive 
plaster. 

CARBUNCULUS. 

(Anthrax.) 

Definition. — A  circumscribed  inflammation  of  the  skin 
and  deeper  tissues,  characterized  by  a  dark-red,  painful  node 
that  breaks  down  and  evacuates  through  several  apertures. 


PSORIASIS.  495 

etiology. — Lowered  vitality  from  any  cause  predisposes. 
They  are  especially  common  in  diabetes.  The  exciting  cause 
is  a  special  microbe. 

Symptoms. — A  dark-red,  painful,  flattened  node  appears, 
surrounded  by  a  dusky-red  area  of  induration.  In  a  week 
or  ten  days  suppuration  begins,  and  the  contents  are  dis- 
charged through  several  orifices.  There  is  generally  marked 
constitutional  disturbance.^  The  most  common  seats  are  the 
nape  of  the  neck,  back,  and  buttocks. 

Prognosis. — Guardedly  favorable.  Death  is  not  an  in- 
frequent termination  in  the  old  and  debilitated. 

Treatment. — Generally  tonics,  like  quinin,  iron,  and 
whisky,  are  indicated.  Opium  may  be  required  to  relieve 
pain. 

Local  Treatment.-^ln  the  early  stage  they  may  be  aborted 
by  a  central  injection  of  lo  to  20  minims  of  a  5  or  10  per 
cent,  solution  of  carbolic  acid  in  glycerin.  When  not  seen 
until  abortion  is  too  late,  firm  compression  may  be  made  by 
straps  applied  concentrically,  leaving  the  central  orifice  free 
for  the  discharge  of  sloughs ;  an  antiseptic  dressing  may  be 
applied  over  the  straps.  If  septicemic  symptoms  appear, 
recourse  must  be  had  to  deep  crucial  incisions  or  extirpation 
of  the  necrotic  tissue. 

PSORIASIS* 

Definition.  —  A  chronic  inflammatory  disease,  char- 
acterized by  red,  scaly,  sharply  circumscribed,  elevated 
lesions. 

Btiology. — Psoriasis  usually  develops  in  young  adults. 
Heredity,  the  gouty  diathesis,  pregnancy,  and  lactation  seem 
to  predispose.  It  is  as  common  in  the  robust  as  in  the  de- 
bilitated.    It  is  non-contagious. 

Pathology. — The  lesions  consist  of  a  marked  hyper- 
plasia of  the  rete  mucosum,  thickening  of  the  horny  layer, 
and  round-cell  infiltration  of  the  corium. 

Symptoms. — Little  red  spots  appear  on  the  body  and 
gradually  grow  until  they  reach  the  size  of  a  dollar.  The 
lesions  are  of  a  dull  pink  or  red  color,  sharply  defined, 


496   DISEASES   OF   THE   SKIN  AND   ITS  APPENDAGES. 

somewhat  elevated,  surrounded  by  healthy  skin,  and  covered 
with  abundant  dry,  pearly,  overlapping  scales.  These  scales 
are  readily  detached,  leaving  behind  a  dry,  slightly  excoriated 
surface.  The  lesions  may  be  uniformly  distributed  over  the 
entire  body,  but  usually  the  extensor  surfaces  are  more 
affected  ;  a  symmetric  arrangement  is  often  observed.  Itch- 
ing is  slightly  or  entirely  absent.  ,  After  a  variable  time  the 
center  of  the  patch  disappears  and  leaves  behind  a  spot  of 
healthy  skin  that  gradually  increases  until  no  trace  of  the 
lesion  remains.  The  disease  runs  a  protracted  course  of 
months  or  years,  improving  in  the  summer  and  growing 
worse  in  the  winter. 

Diagnosis. — Eczema. — In  this  disease  the  patches  are 
not  sharply  defined,  but  shade  off  gradually  into  the  sur- 
rounding skin ;  there  is  marked  itching ;  there  is  usually  a 
decided  discharge,  and  healing  begins  at  the  periphery  in- 
stead of  at  the  center  as  in  psoriasis. 

Seborrhea. — In  this  affection  the  lesions  are  usually  con- 
fined to  the  scalp  and  face,  while  psoriasis  is  general ;  the 
scales  are  gray  and  greasy ;  the  patches  are  not  circum- 
scribed and  lack  the  inflammatory  character  of  psoriasis. 

Papulosquamous  Syphiloderm. — The  history,  the  associated 
symptoms  of  syphilis,  the  coppery  color  of  the  lesions,  the 
scant  scaling,  the  special  tendency  to  involve  the  hands  and 
soles  will  render  the  diagnosis  apparent. 

Prog"nosis. — The  disease  disappears  under  treatment, 
but  relapse  generally  follows  after  a  longer  or  shorter  period. 

Treatment. — The  general  health  may  require  attention. 
In  the  gouty,  alkalis  are  of  value ;  and  in  the  anemic,  iron 
and  cod-liver  oil  are  indicated.  Arsenic  is  often  of  consider- 
able value ;  it  should  be  given  in  small  doses  cautiously 
increased.  lodid  of  potassium  (10  to  20  grains  thrice  daily) 
is  sometimes  recommended. 

Local  Treatment. — The  scales  should  be  removed  by  alka- 
line baths  before  local  applications  are  made.  Th^  best  local 
remedies  are  tar,  oil  of  cade,  chrysarobin,  salicylic  acid, 
resorcin,  sulphur,  and  ammoniated  mercury.  Ointments  of 
chrysarobin  and  mercury  must  not  be  used  over  too  great 
an  area. 


ECZEMA.  497 

R.    Olei  cadin feij 

Adipis 5j. — M. 

SiG. — Apply  night  and  morning. 

Or: 

Jt.    Chrysarobini ^^^j 

Acidi  salicylici gr.  x-xx 

^theris f^j 

.  Olei  ricini YTt^ 

Collodii q.  s.  ad  f^j. — M. 

SiG. — Apply  with  a  camel's-hair  brush  and  paint  over  with  plain 
collodion.  (Stelwagon.) 


ECZEMA. 

(Tetter.) 

Definition. — A  non-contagious  inflammatory  disease  of 
the  skin,  characterized  by  multiform  lesions — erythema, 
papules,  vesicles,  pustules,  scales,  and  crusts — and  asso- 
ciated with  infiltration,  itching,  and  more  or  less  discharge. 

Ktiolog^y. — It  is  most  common  in  the  young  and  in  the 
aged.  Digestive  disturbances,  debility,  gout,  and  rheumatism 
predispose  to  its  development.  It  may  be  due  to  external 
irritants  like  cold,  heat,  the  rhus-plant,  hard  soaps,  certain 
dyes,  etc. 

Pathology. — The  lesions  consist  of  congestion,  with  a 
cellular  and  serous  infiltration  of  the  various  layers  of  the 
skin. 

Varieties. — Eczema  erythematosum,  papulosum,  vesicu- 
losum,  pustulosum,  squamosum,  and  rubrum. 

Eczema  Erythematosum. — This  form  consists  in  irregular 
patches  marked  by  swelling,  redness,  and  slight  scaling,  and 
accompanied  by  itching  and  burning.  The  most  common 
seat  is  the  face. 

Eczema  Papulosum. — In  this  form  there  is  a  close  aggrega- 
tion of  minute  acuminated  papules  accompanied  by  severe 
itching.  It  is  frequently  associated  with  the  vesicular  variety. 
The  most  common  seat  is  the  extremities. 

Eczema  Vesiculosum. — This  consists  in  an  ill-defined  red 
patch  surmounted  by  minute  vesicles,  and  accompanied  by 
intense  itching.  The  vesicles  soon  rupture  and  leave  a  raw, 
weeping  surface  that  becomes  more  or  less   covered  with 

32 


498   DISEASES   OF  THE  SKIN  AND  ITS  APPENDAGES. 

crusts.  In  children  it  is  most  common  on  the  face ;  in 
adults,  on  the  extremities. 

Eczema  Pustulosum  (Eczema  Impetiginosum). — This  consists 
in  an  aggregation  of  small  pustules  that  break  and  lead  to 
the  formation  of  thick  yellowish  crusts.  Itching  is  not 
marked.  It  is  frequently  associated  with  the  vesicular 
variety.  It  is  most  commonly  observed  on  the  face  and 
scalp  of  poorly  nourished  children. 

Eczema  Squamosum. — In  this  form  there  are  irregular  ill- 
defined  red  patches  accompanied  by  considerable  scaling.  It 
differs  from  the  erythematous  form  in  the  large  amount  of 
scaling.     Its  most  common  seat  is  the  scalp. 

When  there  is  a  marked  tendency  to  Assuring,  as  in  chap- 
ping, this  form  is  termed  eczema  fissiim  ;  and  when  there  is 
a  tendency  to  the  formation  of  warty  excrescences,  it  is 
termed  eczcfua  verrucosum. 

Eczema  Rubrum  (Eczema  Madidans). — This  is  a  secondary 
variety  and  is  recognized  by  a  raw,  dark-red,  moist  surface, 
more  or  less  covered  with  thick,  yellowish-red  crusts.  The 
itching  may  be  severe.  In  children  it  is  frequently  noted  on 
the  face,  and  in  old  people  on  the  extremities. 

Diagnosis. — Scabies. — The  history  of  contagion  ;  the 
location  of  the  lesions — between  the  fingers,  on  the  wrists, 
under  the  mammae,  in  the  axillae ;  and  the  presence  of  bur- 
rows will  indicate  scabies. 

Psoriasis. — The  sharply  defined  patches,  the  dry  scaling, 
the  absence  of  marked  itching,  the  symmetric  distribution, 
and  the  predilection  for  extensor  surfaces  will  indicate 
psoriasis. 

Acne  Rosacea. — The  presence  of  acne  papules  and  pustules 
and  of  dilated  blood-vessels  and  the  absence  of  itching  will 
distinguish  acne  rosacea  from  erythematous  eczema. 

Seborrhea. — The  greasy  scales  and  the  absence  of  itching 
and  of  all  inflammatory  symptoms  will  indicate  seborrhea. 

Sycosis. — The  limitation  of  the  lesions  to  the  hair-follicles 
of  the  face  and  the  absence  of  itching  will  distinguish  sycosis 
from  eczema. 

Prognosis. — Generally  favorable  under  persistent  and 
judicious  treatment. 


ECZEMA.  499 

Treatment. — General  Treatment. — The  health  must  be 
improved.  Tonics  are  frequently  indicated.  In  strumous 
children  cod-liver  oil  may  be  of  extreme  value.  Disturb- 
ances of  the  gastro-intestinal  tract  are  frequently  present, 
and  will  require  appropriate  treatment.  In  the  gouty  and 
rheumatic  the  alkaline  mineral  waters,  colchicum,  and  the 
salts  of  lithium  are  indicated.  Constipation  must  always 
receive  attention.  Of  the  special  internal  remedies,  arsenic 
is  the  most  important ;  it  is,  however,  indicated  only  in  the 
chronic  cases  in  which  bright  redness,  itching,  and  weeping 
are  absent. 

External  Treatme7it. — In  acute  cases  with  marked  inflam- 
matory symptoms,  soothing  applications  should  be  employed. 
A  saturated  solution  of  boric  acid  may  be  dabbed  on  for 
five  or  ten  minutes,  and  may  be  followed  by  zinc  ointment 
spread  on  lint ;  when  there  is  much  itching,  carbolic  acid  is 
very  useful : 

R.    Acidi  carbolici :^j 

Glycerini f::^!] 

Aquae q.  s.  ad  fjviij. — M. 

SiG. — Apply  locally. 

The  following  is  also  frequently  used : 

R-    Zinci  oxidi    .    .    .    .    ; ^^ss 

Pulveris  calaminge ^iv 

Glycerini f^iss 

Liquoris  calcis f^viij. — M. 

SiG. — Shake  and  apply  locally. 

In  chronic  cases  crusts  and  scales  should  be  removed  by 
soap  and  water  or  by  : 

R.    Saponis  viridis ,^ij 

Alcoholis ^j. — M. 

SiG. — Apply  thoroughly  and  remove  with  warm  water. 

The  best  external  applications  are  those  containing  salicylic 
acid,  tar,  mercury,  and  resorcin : 

R.    Unguenti  picis  liquidae .^j-ij 

Unguenti  zinci  oxidi    ....      q.  s.  ad  ^j. — M. 
SiG. — Apply  twice  daily. 

Or: 

R.    Hydrargyri  ammoniati gr.  x-xxx 

Unguenti  zinci  oxidi ^. — M. 


500  DISEASES   OF  THE   SKIN  AND   ITS  APPENDAGES. 

LICHEN  RUBER,  LICHEN  PLANUS,  AND  LICHEN 

SCROFULOSIS. 

I/ichen  Ruber. — This  is  an  extremely  rare  disease,  char- 
acterized by  the  eruption  of  small,  red,  glazed,  acuminated 
papules  that  show  no  tendency  to  coalesce,  and  that  are 
associated  with  itching  and  failure  of  general  health.  The 
disease  runs  a  chronic  course,  and  may  prove  fatal  through 
exhaustion. 

I/ichen  Planus. — This  form  is  characterized  by  an  erup- 
tion on  the  extremities  of  small,  red,  flat  papules  that  tend  to 
spread,  and,  by  coalescing,  form  dull-red,  irregular  patches. 
The  lesions  have  an  angular  outhne,  are  slightly  umbilicated,- 
and  at  first  have  a  smooth  and  shiny  appearance,  but  later 
are  slightly  scaly.  There  is  more  or  less  itching,  but  no 
impairment  of  the  general  health.  As  the  old  lesions  disap- 
pear new  ones  take  their  place. 

Etiology. — These  affections  are  most  frequently  observed 
in  poorly  nourished,  middle-aged  males. 

Treatment. — The  general  health  must  be  improved  by 
good  food  and  such  tonics  as  iron,  strychnin,  and  cod-liver 
oil.  Arsenic  is  of  considerable  value.  Locally,  ointments 
of  tar  or  mercury  are  useful. 

I/ichen  Scrofulosis. — This  is  a  chronic  affection  occur- 
ring chiefly  in  children  of  a  strumous  diathesis,  and  charac- 
terized by  small  pale-red  or  salmon-colored  scaly  papules. 
They  tend  to  form  in  groups,  and  are  most  frequently  ob- 
served on  the  trunk.  Itching  is  absent.  The  disease  runs 
a  chronic  course. 

Treatment. — Remedies  like  iron,  quinin,  and  cod-liver  oil 
are  indicated.  Hebra  recommends  the  last  remedy  as  a 
local  application. 

PRURIGO* 

Definition. — A  chronic  inflammatory  disease,  character- 
ized by  a  general  eruption  of  minute,  discrete  papules,  ac- 
companied by  marked  itching. 

!^tiolog"y. — It  is  most  commonly  observed  in  the  poor 
and  ill-fed  of  Europe.  It  develops  in  early  childhood  and 
persists  through  life. 


DERMATITIS  HERPETIFORMIS. 


SOI 


Symptoms. — An  eruption  of  small,  discrete,  deeply  sit- 
uated, pale-red  papules  appears  on  the  body,  especially  on 
the  back  and  extensor  surfaces  of  the  extremities.  The  skin 
is  harsh,  dry,  and  thickened,  and  covered  with  numerous 
scratch-marks  induced  by  the  intense  itching. 

Prognosis. — Unfavorable;  it  usually  persists  through 
life. 

Treatment. — The  general  health  must  be  improved  by 
good  food  and  the  use  of  nutrient  tonics  1-ike  iron  and  cod- 
liver  oil.  Frequent  bathing,  followed  by  ointments  of  tar, 
sulphur,  or  naphthol,  gives  relief. 

DERMATITIS  HERPETIFORMIS- 

(Herpes  Gestationis ;  Duhring's  Disease.) 

Definition. — A  chronic  inflammatory  disease,  character- 
ized by  multiform  lesions  that  form  in  groups  and  are  as- 
sociated with  intense  itching. 

Etiology. — Women  are  more  commonly  affected  than 
men.  Pregnancy,  lactation,  and  menstrual  disorders  seem 
to  exert  a  predisposing  influence. 

Symptoms. — Erythematous  Form. — This  is  characterized 
by  the  appearance,  in  crops,  of  erythematous  patches  that 
are  associated  with  considerable  itching. 

Papular  Form. — Groups  of  papules  appear  in  crops  and 
are  frequently  associated  with  erythema,  vesicles,  and  scratch- 
marks. 

Vesicular  Form. — Groups  of  irregularly  shaped  vesicles 
resembling  herpes  appear  in  crops  and  are  often  associated 
with  erythema,  pustules,  and  scratch-marks. 

Pustiilar  Form. — This  resembles  the  former,  but  the  vesi- 
cles are  replaced  by  pustules. 

Bullous  Form. — Large,  irregularly  shaped  blebs  appear  in 
crops  and  tend  to  group.  Vesicles  and  patches  of  erythema 
are  also  frequently  present. 

Mixed  Form. — Vesicles,  erythematous  patches,  pustules, 
papules,  and  blebs  appear  in  association,  come  out  in  crops, 
and  are  attended  with  intense  itching. 


502    DISEASES   OF  THE  SKIN  AND  ITS  APPENDAGES. 

In  the  pustular,  bullous,  and  mixed  forms  there  may  be 
marked  constitutional  disturbances. 

Prognosis. — Guardedly  favorable.  The  disease  runs  a 
chronic  course.     Relapses  are  very  common. 

Treatment. — Tonics  are  generally  indicated.  Lotions 
of  boric  or  carbolic  acid  may  be  employed  to  allay  itching, 
and  may  be  followed  by  a  dusting-powder. 

DERMATITIS. 

Definition. — Inflammation  of  the  skin  resulting  from  the 
action  of  some  irritant. 

Dermatitis  Traumatica. — This  term  is  applied  to  in- 
flammation of  the  skin  resulting  from  traumatism. 

Treatment. — The  removal  of  the  cause  and  the  application 
of  soothing  remedies  will  usually  sujffice. 

Dermatitis  Venenata. — This  term  is  applied  to  inflam- 
mation of  the  skin  resulting  from  the  application  of  vege- 
table, animal,  or  chemical  irritants.  Notable  examples  of 
this  form  of  dermatitis  are  observed  in  susceptible  people 
after  exposure  to  the  influence  of  poison-ivy  [Rhus  toxico- 
dendron), poison-oak  {RJucs  venenata),  or  poison-sumach 
(Rhus  diversilobd). 

Symptoms  of  Rhus-poisoning. — The  affection  resembles 
acute  eczema,  and  may  appear  in  a  few  hours  or  not  until 
the  lapse  of  several  days  after  exposure  to  the  plant.  It  is 
generally  observed  on  the  face  or  hands.  The  part  becomes 
red  and  swollen,  and  soon  minute  papules  and  vesicles  ap- 
pear. It  gives  rise  to  considerable  burning  and  itching.  As 
a  rule,  it  subsides  in  a  few  days,  but  in  patients  with  sensitive 
skin  it  may  linger  for  several  weeks. 

Treatment. — The  part  should  first  be  bathed  with  Castile 
soap  and  tepid  water,  and  then  treated  with  some  sedative 
lotion  or  ointment.  Black  wash  may  be  dabbed  on,  and 
zinc  ointment  subsequently  applied  ;  or  a  saturated  solution 
of  boric  acid  may  be  followed  by  zinc  ointment.  When 
there  is  marked  itching,  a  weak  solution  of  carbolic  acid  ( i 
dram  to  i  pint)  is  useful.  The  fluid  extract  of  grindelia 
robusta  has  been  highly  recommended ;  it  may  be  applied  in 
the  strength  of  an  ounce  to  a  pint  of  water. 


DERMATITIS.  503 

•Dermatitis  Calorica. — This  term  is  applied  to  the  in- 
flammation of  the  skin  resulting  from  extreme  heat  or  cold. 
Pernio,  or  chilblain,  is  characterized  by  redness,  swelling, 
intense  burning,  and  itching,  and  results  from  a  sudden 
change  from  a  low  temperature  to  a  high  temperature. 
Frost-bite  is  characterized  by  congelation ;  the  part  is  of  a 
dull-white  color  and  is  anesthetic ;  subsequently  inflamma- 
tion or  gangrene  develops. 

Bur?is  and  scalds  result  from  the  application  of  heat,  and 
are  divided  into  degrees  according  to  the  depth  to  which  the 
destructive  process  extends. 

Treatment. — In  pernio,  or  chilblain,  the  part  should  first 
be  rubbed  with  snow  or  bathed  in  ice-water  until  the  circula- 
tion is  reestablished  ;  and  then  an  application  made  of  nitrate 
of  silver  (5  grains  to  the  ounce  of  distilled  water)  or  of 
tincture  of  iodin. 

In  superficial  burns  or  scalds  one  of  the  following  remedies 
may  be  applied :  Phenol  sodique,  Carron  oil  (equal  parts  of 
linseed  oil  and  lime-water),  powdered  bicarbonate  of  sodium, 
or : 

R.    Acidi  carbolici gr.  xx 

Petrolati |ij. — M. 

SiG. — Spread  on  lint  and  apply  to  the  wound. 

Dermatitis  Medicamentosa. — This  term  is  applied  to 
the  various  cutaneous  eruptions  that  follow  the  internal  use 
of  certain  drugs. 

Belladonna  or  Atropin. — These  drugs  produce  a  diffuse 
erythematous  rash  resembling  that  of  scarlet  fever,  but  it 
lacks  the  punctiform  character  of  the  latter.  It  usually  ap- 
pears on  the  face,  neck,  and  chest,  and  is  associated  with 
dryness  of  the  throat,  rapid  pulse,  and,  if  the  dose  has  been 
large,  dilated  pupils. 

Cubebs. — This  drug  sometimes  produces  an  erythema  asso- 
ciated with  minute  papules. 

Copaiba, — The  rash  may  be  macular,  papular,  or  like  that 
of  urticaria. 

Potassium  Bromid. — The  eruption  resembles  acne  and 
consists  of  papules  and  pustules. 

Potassium  lodid. — The   eruption   may  be  erythematous, 


504   DISEASES   OF   THE   SKIN  AND   ITS  APPENDAGES. 

papular,  pustular,  urticarial,  or  purpuric.  The  most  common 
eruption  resembles  acne,  but  the  lesions  are  bright-red  in 
color  and  widely  distributed  over  the  surface  of  the  body. 

Arsenic. — The  eruption  may  be  erythematous,  papular, 
vesicular,  or  pustular. 

Antipyrin. — This  drug  not  infrequently  produces  a  wide- 
spread papular  eruption. 

Qumin. — The  rash  is  usually  erythematous,  though  an 
urticarial  eruption  has  been  observed. 

Salicyl  Compounds. — The  eruption  is  usually  erythematous 
or  urticarial. 

Borax. — This  drug  occasionally  produces  an  eruption  re- 
sembling psoriasis. 

Chloral. — The  eruption  is  usually  erythematous  or  urti- 
carial. 

Dermatitis  Exfoliativa. — This  is  a  rare  affection,  char- 
acterized by  diffuse  redness  of  the  skin,  high  fever  and  its 
associated  phenomena,  and  desquamation.  It  is  interesting 
from  its  close  resemblance  to  scarlet  fever,  from  which  it 
may  be  distinguished  by  the  history  and  the  absence  of  sore 
throat,  and  a  "  strawberry  "  tongue. 

ECTHYMA* 

Definition. — An  inflammatory  affection,  characterized  by 
the  appearance  of  discrete,  flat  pustules,  which  vary  in  size 
from  a  pea  to  a  five-cent  piece,  and  which  are  surrounded  by 
a  distinct  red  areola. 

^Etiology. — Male  sex,  middle  life,  bad  hygiene,  and  de- 
bility are  predisposing  factors. 

Symptoms. — Flat,  yellow  pustules  appear  in  crops.  They 
are  surrounded  by  a  distinct  red  areola  and  soon  dry  up, 
forming  reddish-brown  crusts.  Slight  excoriation  and  pig- 
mentation sometimes  remain  after  the  separation  of  the 
crusts.     Subjective  phenomena  are  usually  absent. 

Diagnosis. — The  acute  course,  the  absence  of  ulcera- 
tion, and  the  absence  of  history  and  of  associated  symptoms 
of  syphilis  will  separate  it  from  the  pustular  syphilid. 

Impetigo. — In  this  affection  the  lesions  are  not  flat ;  they 


PEMPHIGUS.  505 

are  not  distinctly  inflammatory ;  and  the  crusts  are  light 
yellow,  not  reddish-brown.  Impetigo  occurs  most  frequently 
in  children,  who  may  be  quite  robust. 

Prognosis. — Favorable. 

Treatment. — Constitutional  treatment  is  generally  re- 
quired. Such  tonics  as  iron,  quinin,  strychnin,  and  cod-hver 
oil  are  often  indicated. 

Local  Treatment. — The  crusts  should  be  removed  and 
some  stimulating  ointment  applied,  as  the  following : 

]^.    Hydrargyri  ammoniati  .,..,,..  gr.  x 
Unguenti  zinci  oxidi     ........  ^j. — M. 

PEMPHIGUS* 

Definition. — A  non-contagious  inflammatory  disease, 
characterized  by  the  eruption  of  successive  crops  of  bullae 
or  blebs. 

etiology. — Female  sex,  nervous  prostration,  heredity, 
and  injury  to  the  peripheral  nerves  are  predisposing  factors. 

Varieties. — Pemphigus  vulgaris  and  pemphigus  foliaceus. 

Pemphigus  Vulgaris. — This  form  usually  runs  a  chronic 
course,  and  is  characterized  by  successive  crops  of  blebs, 
varying  in  size  from  a  small  pea  to  a  large  walnut.  They 
are  thoroughly  distended  with  fluid,  which  is  at  first  clear, 
but  subsequently  turbid.  As  a  rule,  they  do  not  rupture, 
but  disappear  in  the  course  of  five  or  six  days,  their  contents 
being  gradually  absorbed.  After  absorption  a  thin  pellicle 
remains,  which  dries  and  is  subsequently  detached,  leaving 
behind  a  slightly  pigmented  spot.  No  part  of  the  body  is 
exempt;  and  as  one  set  of  blebs  disappears,  new  ones  rapidly 
develop,  and  so  the  disease  continues  for  many  years. 

In  severe  cases  there  may  be  considerable  itching  and 
burning  attending  the  eruption. 

Pemphigus  Foliaceus. — This  rare  and  grave  form  of  pem- 
phigus is  characterized  by  crops  of  blebs,  -which  are  flaccid 
and  filled  with  a  turbid  fluid  almost  from  the  beginning. 
They  soon  rupture  and  form  thick  crusts,  which,  separating, 
leave  behind  red  weeping  surfaces.  The  crops  follow  each 
other  in  rapid  succession,  and  at  times  the  whole  body  may 


506    DISEASES   OF   THE   SKIN  AND   ITS  APPENDAGES. 

be  covered  with  blebs  and  scabs.  The  disease  may  last 
several  years,  death  ultimately  resulting  from  exhaustion. 

Diagnosis. — Bullous  Syphiloderm. — The  history,  the  asso- 
ciated symptoms  of  syphilis,  the  thick,  yellow,  stratified 
crusts,  and  the  underlying  ulceration  will  serve  to  separate 
this  affection  from  pemphigus. 

Impetigo  Contagiosa. — The  acute  course,  the  contagious 
and  auto-inoculable  character  of  the  affection,  and  the  um- 
bilication  of  the  blebs  will  separate  impetigo  contagiosa  from 
pemphigus. 

Prognosis. — The  prognosis  should  be  guarded.  Pem- 
phigus vulgaris  runs  a  long  course  and  is  often  intractable. 
Pemphigus  foliaceus  often  proves  fatal  through  exhaustion. 

Treatment. — The  diet  should  be  nutritious,  but  care- 
fully adapted  to  the  stomach.  The  patient  should  be  placed 
under  the  best  hygienic  conditions.  Tonics,  like  iron,  quinin, 
phosphorus,  cod-liver  oil,  and  strychnin,  are  usually  indi- 
cated.    In  many  cases  arsenic  is  a  valuable  remedy. 

Local  Treatment. — The  blebs  may  be  punctured  and  sub- 
sequently dressed  with  zinc  ointment. 

IMPETIGO  CONTAGIOSA* 

Definition. — An  acute,  contagious,  inflammatory  disease, 
characterized  by  flat,  yellowish  blebs  that  dry  up  and  form 
thin,  yellow,  lamellated  crusts. 

etiology. — Its  exciting  cause  is  unknown.  It  is  most 
frequently  observed  in  debilitated  children. 

Symptoms. — The  eruption  is  most  frequently  observed 
on  the  face  and  extremities  ;  it  generally  appears  in  crops, 
and  is  at  first  vesicular.  The  vesicles  grow,  and  are  soon 
converted  into  flat,  umbilicated  pustules  which  vary  in  size 
from  a  pea  to  a  large  walnut.  They  have  a  slight  red 
areola.  Itching  is  slight  or  entirely  absent.  In  some  cases 
there  is  moderate  fever  with  its  associated  phenomena.  In  a 
few  days  the  blebs  dry  up  and  form  thin,  yellow,  lamellated 
crusts  that,  separating,  leave  a  slightly  excoriated  surface. 
The  disease  is  contagious,  and  the  lesions  are  auto-inoculable. 

Diagnosis. — Eczema. — In  this  disease  the  pustules  are 


MILIARIA.  507 

deeper,  more  confluent,  excite  intense  itching,  and  are  asso- 
ciated with  inflammation  and  infiltration  of  the  surrounding 
skin. 

Prognosis. — Favorable.  It  terminates  spontaneously  in 
a  few  days  or  weeks. 

Treatment. — A  slight  stimulating  ointment  like  the  fol- 
lowing is  sometimes  useful : 

R.    Hydrargyri  ammoniati gr.  x-xx 

Adipis ^j. — M. 

SiG. — Apply  to  the  surface  after  removal  of  the  crusts. 

MILIARIA. 

(Prickly  Heat.) 

Definition. — A  mild  inflammatory  disease  of  the  sweat- 
glands,  characterized  by  the  occurrence  of  minute  papules 
and  vesicles. 

!^tiology. — Extreme  heat  is  the  principal  predisposing 
cause. 

Symptoms. — The  eruption  generally  appears  on  the 
trunk,  and  consists  of  minute,  closely  aggregated  red  papules 
or  clear  vesicles.  The  lesions  are  discrete,  and  excite  some 
burning  and  itching.  It  is  generally  associated  with  free 
perspiration. 

Diagnosis. — Eczema  papulosum  differs  from  miliaria  in 
that  the  papules  are  larger,  appear  more  gradually,  disappear 
more  slowly,  and  excite  intense  itching. 

Eczema  vesiculosum  differs  from  miliaria  in  that  the  vesicles 
are  large,  disappear  more  slowly,  show  a  tendency  to  break, 
and  are  associated  with  marked  itching. 

Sudamen  differs  from  miliaria  in  that  it  lacks  all  inflamma- 
tory characteristics. 

Prognosis. — Favorable.  Obstinate  cases  may  persist  for 
several  weeks. 

Treatment. — The  general  health  may  require  attention. 
The  diet  should  be  light  and  easily  assimilable.  Constipa- 
tion should  be  reheved  by  saline  laxatives.  Locally,  a  lotion 
of  boric  acid,  followed  by  a  simple  dusting-powder,  is  gen- 
erally all  that  is  required. 


S08    DISEASES   OE  THE   SKIN  AND   ITS  APPENDAGES. 

5t.    Pulveris  amyli ,  ^vj 

Zinci  oxidi ^iss 

Pulveris  camphorse ^ss. — M. 

SiG. — Dusting-powder.  ^  (Hardaway.) 


ALBINISM. 

Definition. — A  congenital  deficiency  of  pigment. 

i^tiology. — Beyond  heredity,  no  cause  is  known.  Partial 
albinism  is  more  common  in  the  negro. 

Symptoms. — In  complete  albinism  the  skin  is  white  ;  the 
hair  is  thin,  soft,  and  very  light  in  color ;  the  pupils  appear 
red,  the  eyes  are  very  sensitive  to  light,  and  the  iris  and 
choroid  are  deficient  in  pigment. 


VITILIGO. 

(Leukoderma.) 

Definition. — An  acquired  cutaneous  affection,  character- 
ized by  milk-white  patches  that  are  surrounded  by  areas  of 
increased  pigmentation. 

i^tiology. — The  disease  seems  to  be  more  common  in 
the  tropics  and  in  the  colored  race.  The  condition  probably 
results  from  disturbed  innervation. 

Symptoms. — Milk-white  spots  appear  on  the  body  and 
grow  very  slowly ;  their  borders  usually  reveal  an  increase 
of  the  normal  pigment.  Apart  from  the  absence  of  pigment 
the  skin  is  normal. 

Diagnosis. — Morphea. — The  initial  hyperemia  and  the 
subsequent  atrophy  of  the  skin  will  serve  to  distinguish 
morphea  from  vitiligo. 

Anesthetic  Leprosy. — The  subjective  symptoms,  the  atrophy 
of  the  tissues,  and  the  anesthesia  will  separate  leprosy  from 
vitiligo. 

Prog'nosis. — Unfavorable;  the  disease  usually  persists 
through  life. 

Treatment. — Tonics  and  local  stimulants  may  be  tried. 
Among  the  latter,  electricity,  bhsters,  and  irritating  oint- 
ments have  been  recommended. 


CANITIES— ATROPHY  OF  THE  HAIR.  509 

CANITIES, 

Definition. — Grayness  of  the  hair. 

^^tiology. — Local  grayness  may  be  congenital  or  result 
from  some  disturbance  of  innervation,  as  in  neuralgia  of  the 
supra-orbital  nerve.  As  a  general  condition  it  is  usually  an 
expression  of  senility,  although  it  occasionally  develops  very 
early  in  life.  Profound  emotional  disturbances  sometimes 
induce  an  abrupt  development  of  canities. 

Prognosis. — The  condition  is  permanent,  and  treatment 
is  of  no  avail. 


ATROPHY  OF  THE  SKIN* 

!^tiolog"y. — Atrophy  of  the  skin  occurs  under  several 
conditions.  A  local  atrophy  may  result  from  inflammation 
or  injury  of  a  nerve-trunk;  in  these  cases  the  wrinkles  are 
absent,  the  skin  is  thin,  smooth,  and  shiny,  and  there  is  often 
intense  burning  in  the  .part  {^'glossy  skin  ").  Atrophy  is  also 
observed  in  leprosy,  morphea,  and  scleroderma. 

Universal  atrophy  of  the  skin  results  from  senility,  and 
very  rarely  as  an  idiopathic  condition.  Sometimes  the 
atrophy  occurs  in  lines  or  spots  {strice  et  inaculcE  atrophiccE) 
as  an  idiopathic  condition,  or  as  the  result  of  stretching  the 
skin,  as  in  the  linecE  albicautes  following  pregnancy. 


ATROPHY  OF  THE  HAIR. 

etiology. — Atrophy  of  the  hair  may  result  from  local 
diseases  that  interfere  with  the  nutrition  of  the  scalp,  such 
as  seborrhea,  eczema,  ringworm,  etc. ;  or  it  very  rarely  arises 
as  an  idiopathic  condition  without  obvious  cause. 

Prognosis. — When  the  cause  can  be  ascertained  and  re- 
moved, the  prognosis  is  favorable. 

Treatment. — Local  diseases  will  require  appropriate 
treatment.  The  general  health  should  be  improved.  Stimu- 
lating applications  of  mercury,  sulphur,  or  carbolic  acid  are 
sometimes  useful. 


5IO  DISEASES   OF  THE  SKIN  AND   ITS  APPENDAGES. 

ATROPHY  OF  THE  NAILS- 

etiology. — Occasionally  the  condition  is  congenital,  but 
more  frequently  it  is  acquired,  and  results  from  injury  or 
disease  of  the  nerve-trunk ;  from  some  general  disease,  like 
one  of  the  fevers,  syphilis,  or  cancer ;  or  from  some  disease 
of  the  skin,  as  psoriasis  or  ringworm. 

Symptoms. — The  nails  lose  their  luster,  cease  to  grow, 
and  become  opaque  and  brittle. 

Prognosis  and  Treatment.— Both  will  depend  on  the 
exciting  cause. 

ALOPECIA* 

(Baldness.) 

etiology. — (i)  Baldness  may  be  congenital ;  in  these 
cases  it  is  usually  partial.  (2)  It  may  be  an  expression  of 
senility,  in  which  case  it  generally  begins  on  the  crown  or 
brow,  and  is  associated  with  more  or  less  atrophy  of  the 
scalp.  (3)  It  may  occur  early  in  life,  as  an  idiopathic  affec- 
tion arising  without  obvious  cause.  (4)  It  may  result  from 
general  diseases,  like  syphilis  and  the  fevers.  (5)  In  early 
life  it  is  often  due  to  some  local  disease,  especially 
seborrhea. 

Prognosis. — In  congenital,  senile,  and  idiopathic  alopecia 
the  prognosis  is  unfavorable.  In  the  alopecia  of  general 
diseases  the  prognosis  is  usually  favorable.  In  alopecia 
resulting  from  seborrhea  much  can  be  accomplished  by  per- 
sistent and  judicious  treatment. 

Treatment. — The  general  health  should  be  improved. 
Frequently  washing  the  head  with  warm  water  and  Castile 
soap  is  to  be  recommended.  One  of  the  following  local 
stimulants  may  be  prescribed  :  Cantharides,  quinin,  alcohol, 
capsicum,  sulphur,  or  carbolic  acid. 

R.    Tincturse  cantharidis f^j 

Acidi  carbolici ^j 

Olei  ricini 3;iss 

Spiritus  myrcise 

Spiritus  lavandulae      aa  fjij. — M. 


ALOPECIA   AREATA.  5II 

Or: 

R.    Tincturse  cantharidis f^ij 

Quininse  sulphatis gr.  x 

Glycerini fgij 

Olei  rosmarini gtt.  v 

Spiritus  myrcise q.  s.  ad  f^v. — M. 

When  there  is  much  dandruff,  the  following  lotion  will  be 
found  useful : 

R.     Resorcinolis 3^ 

Acidi  salicylic! gr.  xxx-^j 

Olei  ricini f.^ss-j 

Olei  bergamottge f^j 

Alcoholis q.  s.  ad  f|vj. — M. 

(SCHAMBERG.) 

ALOPECIA  AREATA. 

(Alopecia  Circumscripta.) 

Definition. — Baldness  appearing  in  circumscribed  patches 
without  any  obvious  lesion  of  the  skin. 

!^tiology. — The  cause  is  unknown.  Some  regard  it  as  of 
parasitic  origin,  while  others  look  upon  it  as  a  neurosis.  It 
is  generally  observed  in  early  adult  life. 

Symptoms. — The  disease  is  characterized  by  the  sudden 
or  gradual  appearance  of  circumscribed  round  patches  of 
baldness.  At  first  there  is  no  change  in  the  appearance  of  the 
skin,  but  later  it  may  become  pale  and  atrophied.  Although 
the  scalp  is  the  most  frequent  seat,  it  occasionally  involves 
other  hairy  parts,  as  the  eyebrows,  beard,  etc. 

Diagnosis. — Ringworm. — Ringworm  is  exceedingly  rare 
in  adults,  and  is  characterized  by  elevated  scaly  patches 
through  which  project  dry,  brittle,  broken  hairs.  If  there 
should  be  any  doubt  in  the  diagnosis,  the  microscope  may 
be  employed  to  detect  the  trichophyton. 

Prognosis. — In  the  majority  of  cases  the  hair  returns 
under  prolonged  and  persistent  treatment.  The  older  the 
patient,  the  less  favorable  the  prognosis. 

Treatment, — General  tonics,  like  iron,  arsenic,  quinin, 
and  strychnin,  are  usually  indicated.  The  local  treatment 
should  be  stimulating  and  consist  in  the  application  of 
blisters,  electricity,  friction,  rubefacient  Hniments,  or  oint- 


512    DISEASES   OF   THE   SKIN  AND   ITS  APPENDAGES. 

ments  containing  chrysarobin,  tar,  sulphur,  or  ammoniated 
mercury. 

Y^.    Tincturas  cantharidis 

Tincturse  capsici aa  f^ss 

Olei  ricini .  f^^ss 

Spiritus  rosmarini ,    .    .    .  fj^ij 

Alcoholis      f^j. — M. 

Or: 

R.     Betanaphtholis gr.  xl-^j 

Petrolati |j. — M. 

SYCOSIS- 

(Simple  Sycosis;   Folliculitis  Barbae.) 

Definition. — A  non-contagious  inflammatory  disease  of 
the  hair-follicles. 

etiology. — The  affection  results  from  local  irritation  and 
the  entrance  of  pyogenic  cocci. 

Symptoms. — The  disease  usually  manifests  itself  on  the 
bearded  region  of  the  face,  and  is  characterized  by  an  aggre- 
gation of  papules  and  pustules,  each  of  which  is  pierced  by 
a  hair.  When  the  lesions  are  discrete,  the  intervening  skin 
is  often  quite  healthy ;  but  when  they  are  close  together,  it  is 
often  infiltrated  and  hyperemic.  During  the  papular  stage 
the  hairs  are  not  loose,  but  firmly  attached ;  during  the  pus- 
tular stage,  however,  they  can  be  readily  extracted.  The 
pustules  show  no  tendency  to  rupture,  but  dry  to  yellowish- 
brown  crusts.  Acute  cases  are  associated  with  more  or  less 
burning  and  itching.  If  the  disease  persists,  it  may  lead  to 
extreme  destruction  of  the  hair-follicles,  and,  as  a  conse- 
quence, to  permanent  alopecia. 

Diagnosis. — Eczema. — The  lesions  in  eczema  excite  se- 
vere itching,  are  not  perforated  by  hairs,  and  are  not  confined 
to  the  hairy  parts. 

Tinea  Sycosis,  or  Barber's  Itch. — The  affection  begins  as  a 
red,  scaly  patch,  and  is  followed  by  the  development  of  large, 
deeply  seated  tubercles.  The  hairs  soon  become  dry,  brittle, 
and  broken  off,  and  can  easily  be  extracted.  In  doubtful 
cases  the  microscope  may  be  employed  for  the  detection  of 
the  trichophyton. 


POMPHOL  YX.  513 

Prognosis. — The  disease  is  curable  under  prolonged 
and  judicious  treatment.  Relapses  are  very  prone  to 
occur. 

Treatment. — In  acute  cases  soothing  applications  are 
indicated ;  thus  the  parts  may  be  dabbed  with  black  wash  or 
a  saturated  solution  of  boric  acid,  and  subsequently  spread 
with  oxid  of  zinc  ointment.  In  chronic  cases  the  crusts 
should  be  removed,  and  the  hairs  cut  close  or,  preferably, 
shaved.  It  is  advisable  to  puncture  the  pustules  and  to  ex- 
tract the  hairs,  so  as  to  preserve  the  follicles.  When  the  parts 
are  not  irritable,  stimulating  applications  are  useful,  and  one 
of  the  following  may  be  selected : 

R.    Sulphuris  prjecipitatis gr.  xxx-^iss 

Unguenti  aquae  rosse ^j. — M. 

SiG. — Apply  twice  daily. 

Or: 

R.    Ichthyol .^j 

Petrolati ^j. 

SiG. — Apply  twice  daily. 


POMPHOLYX. 

(Dysidrosis.) 

Pompholyx  is  a  very  rare  disease,  usually  observed  in 
those  who  perspire  freely,  and  characterized  by  an  eruption 
of  deeply  seated  vesicles  that  resemble  sago-grains  imbedded 
in  the  skin.  The  vesicles  most  commonly  appear  on  the 
hands,  especially  between  the  fingers,  and  gradually  increase 
in  size  until  they  reach  the  dimensions  of  blebs.  They  show 
no  tendency  to  rupture,  but  dry  up,  and  are  followed  by 
extensive  desquamation  of  the  cuticle.  The  eruption  often 
excites  considerable  pain  and  tenderness.  The  disease 
usually  disappears  in  the  course  of  a  few  weeks,  but  is 
prone  to  recur. 

Treatment. — General  tonics,  like  iron,  strychnin,  and 
arsenic,  are  often  indicated.  Locally,  sedative  lotions  or 
ointments  should  be  employed. 

33 


514    DISEASES   OF  THE  SKIN  AND  ITS  APPENDAGES. 

LENTIGO. 

(freckie.) 

Definition. — A  deposition  of  pigment  in  the  form  of 
small,  irregularly  shaped  brownish  spots. 

Ktiolog"y. — Blondes  are  more  subject  to  the  affection  than 
brunettes.  Exposure  to  the  sun's  rays  often  serves  as  an 
exciting  cause. 

Symptoms. — Exposed  parts — the  face,  shoulders,  arms, 
and  hands — are  mostly  affected.  The  patches  vary  in  color 
from  yellow  to  dark  brown,  and  range  in  size  from  a  pin- 
head  to  a  pea. 

Prognosis. — Freckles  can  be  removed,  but  they  always 
return. 

Treatment. — One  of  the  best  remedies  is  the  bichlorid 
of  mercury  in  solution  or  ointment. 

.R.    Hydrarg.  chlor.  corros =    gr.  iv-viij 

Alcoholis  et  aquae    .    .    .    .    aa  q.  s.  ad  f^iv. — M. 
SiG. — Apply  twice  daily. 

CHLOASMA* 

Definition. — An  abnormal  deposition  of  pigment  in  the 
form  of  large  brown  or  liver-colored  patches. 

etiology. — It  may  result  from  the  application  of  external 
irritants ;  from  general  diseases  like  malaria  and  Addison's 
disease;  or  from  affections  of  the  uterus,  as  pregnancy, 
tumors,  etc. 

Symptoms. — The  affection  consists  in  the  appearance- — 
especially  on  the  face — of  large,  round,  or  irregularly  shaped 
brownish  or  blackish  patches.  Apart  from  the  discoloration 
the  skin  is  normal. 

Diagnosis. — In  leukoderma  the  periphery  of  the  patches 
is  pigmented,  but  the  central  milk-white  appearance  is  not 
seen  in  chloasma. 

Prognosis. — When  the  cause  can  be  removed,  the  prog- 
nosis is  favorable. 

Treatment. — Wb*en  possible,  the  cause  should  be  fe- 


KERATOSIS  PILARIS— MOLLUSCUM  EPITHELIALE.    515 

moved.     The  best  local  remedies  are  bichlorid  of  mercury 
and  sulphur. 

R.    Hydrargyri  chloridi  corrosivi      .    .    .    .    gr.  iij-xij 

Acidi  acetici  diluti f^ij 

Sodii  boratis .    .    .    gr.  xl 

Aquse  rosse q.  s.  ad  f^iv. — M. 

SiG. — Apply  night  and  morning.  (HARDY.) 

KERATOSIS  PILARIS. 

(Lichen  Pilaris.) 

Definition. — Small,  papular  elevations  resulting  from 
hypertrophy  of  the  epidermis  surrounding  the  outlets  of  the 
hair-follicles. 

etiology. — It  generally  results  from  infrequent  bathing. 

Symptoms. — The  skin,  particularly  on  the  extensor  sur- 
faces of  the  arms  and  legs,  is  the  seat  of  numerous  pin-head 
elevations  which  have  a  dirty-gray  color  and  are  pierced  by 
hairs.  It  may  excite  some  itching.  Generally  there  are  no 
evidences  of  inflammation,  but  sometimes  a  few  red  papules 
or  even  pustules  result  from  irritation. 

Diagnosis. — In  cutis  anserina,  or  goose-flesh,  the  lesions 
are  transient  and  have  the  color  of  normal  skin. 

Prognosis. — Favorable. 

Treatment. — In  most  cases  nothing  will  be  required  be- 
yond frequent  bathing  with  soap,  followed  by  friction  of  the 
skin.  In  obstinate  cases  some  simple  ointment  may  be  ap- 
plied after  bathing. 

MOLLUSCUM  EPITHELIALE. 

(MoUuscum  Contagiosum ;  Molluscum  Sebaceum.) 

Definition. — A  cutaneous  affection,  characterized  by  the 
appearance  of  discrete,  wax-like  elevations  ranging  in  size 
from  a  pin-head  to  a  pea,  and  varying  in  color  from  white  to 
rose-pink. 

!^tiology. — The  disease  is  generally  observed  in  children, 
and  frequently  affects  several  members  of  the  same  house- 
hold, school,  or  asylum.     It  is  probably  contagious. 


5l6  DISEASES   OF  THE   SKIN  AND   ITS  APPENDAGES. 

Symptoms. — Small  white  or  pale-pink,  wax-like  eleva- 
tions ^  appear,  especially  on  the  face.  They  are  always  dis- 
crete and  rarely  abundant.  The  center  of  the  elevation  is 
depressed  and  reveals  a  dark  spot  that  corresponds  to  the 
aperture  of  the  folHcle.  At  first  the  lesions  are  quite  firm, 
but  as  they  grow  old  they  become  soft.  When  firmly 
squeezed,  they  exude  a  soft,  cheesy  material.  After  remain- 
ing for  several  weeks  they  break  down  or  undergo  slow 
absorption. 

Diagnosis. — The  color,  the  wax-like  appearance,  the 
umbilication,  and  the  central  aperture  are  the  diagnostic 
features. 

Prognosis. — Favorable,  although  the  disease  may  run  a 
protracted  course  of  months  or  years. 

Treatment. — General  tonics,  like  iron,  strychnin,  and 
arsenic,  are  often  indicated.  The  lesions  should  be  incised, 
the  contents  expressed,  and  their  bases  touched  with  nitrate 
of  silver;  ointments  of  mercury  and  sulphur  have  also  been 
recommended. 

CALLOSITAS. 
(Callus ;  Keratoma ;  Tylosis.) 

Definition. — A  thickened,  horny  condition  of  the  skin 
resulting  from  hypertrophy  of  the  corneous  layer  of  the 
epidermis. 

!^tiology. — Constant  irritation  from  friction  or  pressure 
is  the  chief  cause ;  hence  it  is  frequently  seen  on  the  feet 
from  the  rubbing  of  shoes,  and  on  the  hands  from  the  fric- 
tion of  tools. 

Symptoms. — The  condition  is  characterized  by  the  ap- 
pearance of  hard,  thickened,  grayish  masses,  which  gradually 
merge  into  healthy  skin.  The  soles  and  palms  are  the  parts 
most  frequently  affected.  When  slight,  it  causes  little  incon- 
venience, but  occasionally  it  becomes  fissured  and  painful. 

Prognosis. — It  yields  rapidly  to  treatment  when  the  cause 
is  removed. 

Treatment. — When  excessive,  the  parts  should  be  soaked 
and  the  thickened  epidermis  pared  off.  One  of  the  best 
remedies   for  softening   the  horny  overgrowth  is  saHcylic 


CLA  VUS—CORNU  CUTANE UM.  5  I  / 

acid ;  it  may  be  applied  in  the  form  of  a  plaster  or  in  col- 
lodion. 

R.    Acidi  salicylici i^j 

Olei  ricini fftx 

Collodii f^j-— M. 

SiG. — Apply  night  and  morning. 

CLAVUS- 

(Corn.) 

Definition. — Clavus  is  a  circumscribed  thickening  of  the 
epidermis  usuall)^  appearing  on  the  feet. 

;^tiolog"y. — Corns  generally  result  from  the  friction  of 
ill-fitting  shoes. 

Symptoms. — Small,  circumscribed,  horny  elevations  ap- 
pear upon  the  feet  and  often  excite  severe  pain.  When 
bathed  in  perspiration,  they  become  more  or  less  macerated, 
and  in  this  condition  constitute  the  so-called  soft  corn. 

Treatment. — A  radical  cure  requires  the  use  of  well- 
fitting  shoes.  The  corns  may  be  removed  by  soaking, 
paring,  and  the  application  of  some  mild  caustic  Hke  salicylic 
acid. 

R.    Acidi  salicylici gr.  xxx 

Tincturge  iodi YlXx 

Extracti  cannabis  indicse g^"-  ^ 

Collodii fjss.— M. 

SiG. — Apply  night  and  morning  for  several  days,  and  then  soak 
in  hot  water. 

CORNU  CUTANEUM. 
(Cutaneous  Horn.) 

Definition. — A  circumscribed,  projecting  outgrowth  re- 
sulting from  hypertrophy  of  the  epidermis. 

Symptoms. — Horns  generally  appear  on  the  face,  scalp, 
or  penis,  and  are  usually  observed  in  the  old.  They  consist 
of  dry,  rough,  horny,  more  or  less  conic  projections,  which 
vary  in  length  from  a  few  lines  to  several  inches. 

Prognosis. — Favorable. 

Treatment. — The  horn  should  be  excised  and  the  base 
subsequently  cauterized. 


5l8   DISEASES   OF   THE   SKIN  AND   ITS  APPENDAGES. 

VERRUCA- 

(Wart.) 

Definition. — A  wart  is  a  circumscribed  elevation  result- 
ing from  hypertrophy  of  the  papillae  and  epidermis. 

Etiology. — The  cause  is  obscure.  A  bacterial  origin 
has  been  suggested.  They  are  most  frequently  observed  in 
children. 

Symptoms. —  Verruca  vulgaris,  or  common  wart,  is  gen- 
erally observed  on  the  hands  of  children.  It  consists  of  a 
firm,  circumscribed  elevation,  varying  in  size  from  a  millet- 
seed  to  a  pea. 

Verruca  plana,  or  flat  wart,  is  a  circumscribed,  flat,  pig- 
mented elevation  usually  observed  on  the  backs  of  old 
people. 

Verruca  Filiformis. — This  is  a  thread-like  overgrowth,  and 
is  generally  observed  on  the  soft  parts,  like  the  face  and 
neck. 

Veri'uca  Digitata. — This  form  is  made  up  of  numerous 
branches,  and  is  generally  observed  on  the  scalp. 

Verruca  Acumhiata,  or  Venereal  Wart. — This  appears  in 
groups  about  the  genitalia.  It  is  soft,  red  in  color,  and 
highly  vascular.  It  may  be  dry  or  moist,  according  to  its 
location ;  the  latter  condition  often  gives  rise  to  a  peculiarly 
offensive  odor. 

Treatment. — Ordinary  warts  may  be  removed  by  ex- 
cision, caustics,  or  electrolysis. 

Venereal  warts  should  be  bathed  in  some  antiseptic  solu- 
tion and  subsequently  dusted  with  calomel,  iodoform,  or 
boric  acid. 

NAEVUS  PIGMENTOSUS. 

(Mole.) 

Definition. — A  circumscribed  deposit  of  pigment,  usually 
associated  with  hypertrophy  of  cutaneous  structures. 

Ktiology. — Moles  are  usually  congenital. 

Symptoms. — The  neck,  face,  and  trunk  are  favorite 
localities.  The  nevi  vary  in  number  from  one  to  several 
hundred ;   in  size,  from  a  millet-seed  to  a  filbert ;    and  in 


ICHTHYOSIS—  ONYCHA  UXIS.  5  1 9 

color,  from  yellow  to  black.  When  the  surface  is  smooth, 
the  growth  is  termed  ncEvits  spilus ;  when  the  surface  is  cov- 
ered with  hair,  it  is  termed  ncevtis  pilosiis ;  when  the  surface 
is  warty,  it  is  termed  ncevus  verrucosus ;  and  when  there  is 
much  overgrowth  of  connective  tissue,  it  is  termed  ncevus 
liponiatodes. 

Treatment. — They  may  be  removed  by  excision,  the 
application  of  caustics,  or  by  electrolysis. 

ICHTHYOSIS. 

(Fish-skin  Disease.) 

Definition. — A  chronic  affection,  characterized  by  dry- 
ness, thickening,  and  scaliness  of  the  epidermis. 

]^tiology. — The  affection  is  often  hereditaiy,  and  is 
usually  detected  in  early  childhood. 

Symptoms. — The  skin  is  dry  and  harsh ;  the  surface  is 
covered  with  adherent  polygonal  scales  ;  and  the  papillae  are 
more  or  less  hypertrophied.  The  term  ichthyosis  hystrix  is 
applied  to  the  condition  when  there  is  excessive  hypertrophy 
of  the  papillae.  The  extensor  surfaces  of  the  extremities 
are  the  parts  most  involved. 

Diagnosis. — The  absence  of  all  inflammatory  symptoms 
will  separate  ichthyosis  from  squamous  eczema  2iV\d  psoiHasis, 

Prognosis. — The  disease  is  incurable,  but  the  patient 
can  be  rendered  comfortable  by  appropriate  treatment. 

Treatment. — The  scales  may  be  removed  by  alkaline 
baths  or  by  applications  of  green  soap.  The  skin  may  be 
rendered  pliable  by  rubbing  in  some  simple  ointment. 

R.     Sulphuris gr.  xxv-1 

Adipis %]. — M. 

SiG.— Rub  in  at  night.  (Unna.) 

ONYCHAUXIS. 

Onychauxis,  or  hypertrophy  of  the  nail,  may  be  con- 
genital, or  may  result  from  certain  skin  affections,  such  as 
eczema,  ringworm,  or  syphilis  ;  from  diseases  of  the  nerves, 
as  neuritis  ;  or  from  traumatism. 


520  DISEASES   OF   THE   SKIN  AND   ITS  APPENDAGES. 

HYPERTRICHOSIS- 

(Hirsuties.) 

Hypertrichosis,  or  hypertrophy  of  the  hair,  may  be  local 
or  general.  The  term  is  applied  not  only  to  an  excessive 
overgrowth  of  hair,  but  to  a  growth  of  hair  in  unusual 
localities,  as  on  the  faces  of  young  women. 

Treatment. — The  hair  may  be  removed  temporarily  by 
shaving,  epilation,  or  depilatories.  Permanent  relief  can  be 
accomplished  only  by  electrolysis. 

SCLERODERMA* 

(Sclerema ;  Scleriasis.) 

Definition. — A  pigmented,  rigid,  indurated  condition  of 
the  skin,  occurring  in  circumscribed  patches  or  involving  the 
entire  body. 

!^tiologfy. — The  cause  is  unknown. 

Symptoms. — The  affection  may  be  diffuse  or  involve  cir- 
cumscribed patches.  It  may  appear  quite  suddenly,  or  de- 
velop very  gradually  in  the  course  of  months  or  years.  The 
skin  assumes  a  yellowish-brown  color,  becomes  rigid,  in- 
durated, and  hide-bound  ;  the  surface  is  unnaturally  dry  and 
smooth.  When  the  condition  is  advanced,  the  joints  become 
more  or  less  immobile. 

Prognosis. — Guarded.  It  often  recovers  spontaneously 
after  having  persisted  for  a  long  time.  In  other  cases  the 
process  may  spread  until  the  patient  becomes  almost  helpless. 

Treatment. — Tonics,  like  iron,  arsenic,  and  cod-liver  oil, 
are  often  indicated.  Locally,  massage,  friction,  electricity, 
and  inunctions  are  recommended. 

MORPHEA* 

(Addison's  Keloid.) 

Definition.— A  cutaneous  affection,  characterized  by  cir- 
cumscribed, rounded,  ivory-like  patches,  which  have  hyper- 
emic  or  pigmented  borders. 

!^tiology. — The  cause  is  unknown.  By  many  it  is  re- 
garded as  a  circumscribed  form  of  scleroderma. 


ELEPHANTIASIS.  521 

Symptoms. — The  lesions  usually  appear  upon  the  trunk, 
and  consist  of  sharply  circumscribed  patches,  which  are  at 
first  slightly  hyperemic.  The  surface  is  smooth  and  resistant 
to  the  touch.  As  the  patch  grows  old  its  center  becomes 
pale  and  ivory-like,  while  the  periphery  remains  hyperemic 
or  becomes  pigmented. 

Prognosis. — Guarded. 

Treatment. — The  same  as  scleroderma. 

ELEPHANTIASIS* 

(Elephantiasis  Arabum ;  Elephantiasis  Pachydermia ;  Barbadoes 

Leg.) 

Definition. — Hypertrophy  of  the  skin  and  subcutaneous 
tissues,  usually  associated  with  lymphangitis,  edema,  and 
pigmentation. 

i^tiology. — While  elephantiasis  may  occur  in  any  part 
of  the  world,  it  is  far  more  common  in  the  tropics.  It  is 
most  frequently  observed  in  the  male  sex,  and  rarely  de- 
velops before  adult  life.  It  results  from  obstruction  of  the 
lymphatics,  and  the  most  common  cause  of  such  obstruction 
is  the  presence  of  a  parasite — Pllaria  sanguinis  hominis. 

Pathology. — Examination  of  the  affected  tissues  reveals 
hypertrophy  of  the  connective  tissue,  edema,  and  inflamma- 
tion and  dilatation  of  the  lymphatic  vessels. 

Symptoms. — It  usually  begins  with  recurring  attacks  of 
erysipelatoid  inflammation.  The  part  is  red,  swollen,  and 
painful ;  the  lymphatics  may  be  traced  as  branching  red  lines 
beneath  the  skin ;  and  with  these  local  phenomena  there  is 
more  or  less  fever.  After  each  attack  the  part  is  left  a  little 
enlarged,  until  finally  it  presents  the  following  characteristic 
appearance:  it  is  enormously  swollen;  the  skin  is  thickened, 
roughened,  and  pigmented  ;  and  the  papillae  are  unusually 
prominent.  The  regions  generally  affected  are  the  legs  and 
genitals.  In  elephantiasis  of  the  scrotum  (lympli-scrotiini) 
the  hypertrophied  mass  may  weigh  as  much  as  50  or  even 
100  pounds. 

Prognosis. — In  the  early  stage  the  disease  may  be  ar- 
rested, but  when  fully  established,  it  is  incurable. 


522    DISEASES   OF   THE   SKIN  AND  ITS  APPENDAGES. 

Treatment. — The  acute  inflammatory  attacks  should  be 
treated  by  rest  and  the  application  of  sedative  lotions,  like 
lead-water  and  laudanum.  Subsequently  mercurial  inunc- 
tions may  be  employed,  and  the  part  firmly  bandaged  with 
the  view  of  promoting  absorption.  Amputation  may  be 
successfully  employed  in  lymph-scrotum.  In  elephantiasis 
of  the  limbs  ligation  of  the  main  artery  has  given  somewhat 
encouraging  success. 

DERMATOLYSIS* 

(Pachydermatocele;   Cutis  Pendula.) 

Definition. — A  circumscribed  hypertrophy  of  the  skin 
and  subcutaneous  tissues  resulting  in  a  softened  and  pendu- 
lous condition  of  the  integument. 

Symptoms. — The  part  affected  is  thickened  and  pig- 
mented ;  it  is  soft  and  fat-like  to  the  touch ;  and  when  the 
condition  is  marked,  the  skin  hangs  in  folds.  The  regions 
generally  affected  are  the  shoulders,  arms,  back,  and  buttocks. 

Treatment. — The  redundant  tissue  may  be  removed  by 
excision  or  electrolysis. 

KELOID. 

(Cheloid;  Kelis.) 

Definition. — A  new  growth  resulting  from  hypertrophy 
of  the  connective  tissue  of  the  corium. 

etiology. — It  generally  results  from  local  injury,  though 
it  is  claimed  that  it  may  arise  spontaneously.  Certain  fami- 
lies and  individuals  are  especially  predisposed.  It  is  more 
frequent  in  the  colored  race. 

Symptoms. — It  begins  as  a  pale-red  nodule,  which  slowly 
increases  in  size  and  sends  out  claw-like  processes.  From 
its  resemblance  to  a  crab  it  has  been  termed  keloid.  It  is 
firm,  elastic,  slightly  elevated,  sharply  defined,  and  ranges 
in  size  from  a  small  bean  to  a  growth  as  large  as  the  hand. 
It  sometimes  excites  pain  and  itching,  but  generally  sub- 
jective phenomena  are  absent.  The  regions  most  frequently 
involved  are  the  chest  and  back. 


FIBR  OMA—A  NGIOMA .  523 

Diagnosis. — Keloid  may  be  distinguished  from  a  hyper- 
trophied  scar  by  the  fact  that  the  latter  does  not  extend  be- 
yond the  limits  of  the  injury. 

Prognosis. — The  growth  is  usually  permanent,  and  after 
removal  invariably  returns. 

Treatment. — It  may  be  removed  temporarily  by  excision, 
electrolysis,  or  caustic  pastes. 

FIBROMA. 

(MoUuscum  Fibrosum.) 

Definition. — A  circumscribed  overgrowth  derived  from 
the  subcutaneous  connective  tissue. 

etiology. — Early  life  and  heredity  are  predisposing  fac- 
tors. 

Symptoms. — The  tumors  are  circumscribed  ;  painless  ; 
soft  or  firm ;  often  multiple ;  range  in  size  from  a  pea  to  a 
hen's  ^g%\  and  do  not  impair  the  general  health.  The  over- 
lying skin  may  be  normal  in  appearance  or  slightly  hyper- 
emic. 

Prognosis. — They  are  permanent  and  treatment  is  rarely 
indicated. 

ANGIOMA* 
(Naevus  Vasculosus.) 

Definition. — A   new   growth,    composed    of  cavernous 

tissue  or  a  congeries  of  small  blood-vessels. 

Angioma  Cavernosum. — This  form  is  congenital,  is  com- 
posed of  cavernous  tissue,  and  appears  as  a  circumscribed, 
elevated,  dark-red  tumor  that  ranges  in  size  from  a  pea  to 
one  as  large  as  the  hand.     It  is  often  lobulated  and  pulsating. 

Angioma  Simplex  (Capillary  Nevus  ;  Port-wine  Mark). — This 
form  is  also  congenital,  and  is  composed  of  a  congeries  of 
capillaries.  It  is  non-elevated,  bright-red  or  purple-red  in 
color,  and  may  cover  an  area  of  several  inches.  It  is  gen- 
erally found  on  the  face,  and  constitutes  what  is  popularly 
termed  a  viothe7''''s  mark. 

Telangiectasis. — This  form  is  acquired,  and  is  composed  of 
dilated  or  newly  developed  capillaries.    It  appears  as  a  bright- 


524  DISEASES   OF  THE  SKIN  AND  ITS  APPENDAGES. 

red  dot  from  which  branch  dilated  capillaries.  It  is  fre- 
quently associated  with  acne  rosacea ;  it  is  also  common  in 
those  of  a  gouty  diathesis  and  in  those  much  exposed  to  the 
weather. 

Treatment. — Cavernous  angiomata  may  be  removed  by 
ligation,  excision,  or  electrolysis.  Simple  angiomata  and 
telangiectasis  are  best  treated  by  electrolysis. 

XANTHOMA^ 

(Vitiligoidea ;  Xanthelasma.) 

Definition. — A  circumscribed  connective-tissue  new- 
growth  appearing  as  flat  patches  or  tubercles  of  a  yellowish 
color. 

etiology. — Middle  life  and  female  sex  are  general  pre- 
disposing factors.  Hepatic  disorders,  especially  obstructive 
jaundice,  seem  to  exert  a  decided  predisposing  influence. 

Symptoms. — There  are  two  forms  :  xanthoma  planum^ 
which  generally  appears  about  the  eyelids  and  consists  of 
smooth,  circumscribed,  slightly  elevated,  buff-colored  patches ; 
and  xantho7na  Utberosum,  which  may  appear  on  the  neck, 
shoulders,  trunk,  or  extremities,  and  consists  of  small,  elastic, 
and  yellowish-colored  nodules. 

Treatment. — These  growths  may  be  removed  by  ex- 
cision, electrolysis,  or  caustics. 

LUPUS  ERYTHEMATOSUS. 

(Seborrhoea  Congestiva.) 

Definition. — Lupus  erythematosus  is  a  new-growth  re- 
sulting from  a  cellular  infiltration  of  the  skin,  and  character- 
ized by  circumscribed,  red  patches  that  are  more  or  less 
covered  with  yellowish-gray  adherent  scales. 

l^tiology. — Middle  life  and  female  sex  are  predisposing 
factors.  It  frequently  arises  from  disorders  of  the  sebaceous 
glands,  as  seborrhea  or  acne. 

Pathology. — By  many  it  is  regarded  as  a  chronic  derma- 
titis which  originates  in  the  sebaceous  glands. 


LUPUS  ERYTHEMATOSUS.  525 

Symptoms. — The  disease  usually  manifests  itself  on  the 
face,  in  the  region  of  the  nose,  and  appears  as  small,  red, 
sHghtly  elevated  papules,  which  are  more  or  less  scaly.  An 
erythematous  patch  is  gradually  formed  by  the  coalescence 
of  these  papules.  The  periphery  of  the  patch  is  elevated  and 
sharply  defined,  while  the  center  is  depressed  and  atrophied. 
The  ducts  of  the  sebaceous  glands  are  dilated  and  often 
filled  with  sebum.  The  disease  spreads  very  slowly,  shows 
no  tendency  to  ulceration,  and  rarely  excites  any  subjective 
symptoms. 

Diagnosis. — The  location,  the  sharply  defined  red  patch 
with  an  elevated  margin  and  depressed  center,  the  slight 
scahness,  the  dilated  sebaceous  ducts,  the  chronic  course, 
and  the  absence  of  ulceration  are  the  diagnostic  features. 

Lupus  Vulgaris. — This  affection  begins  earlier  in  life,  is 
characterized  by  tubercles  and  ulceration,  and  lacks  involve- 
ment of  the  sebaceous  glands. 

Prognosis. — Favorable  under  prolonged  and  judicious 
treatment. 

Treatment. — General  tonics,  like  iron,  arsenic,  phos- 
phorus, and  cod-liver  oil,  are  often  indicated. 

Local  Treatment. — In  many  cases  mild  applications  accom- 
plish the  most  good.  Much  benefit  is  often  derived  from 
washing  the  part  thoroughly  with  green  soap  and  alcohol 
for  a  few  days  and  then  applying  the  following  lotion : 

R.     Zinci  sulphatis 

Potassii  sulphidi ^^  -^jj. 

Aqu3e         f.^iij 

Alcoholis      f^j-— M. 

SiG.— Shake  well,  dab  the  parts  for  fifteen  minutes  twice  daily, 
and  allow  to  dry  on.  (DUHRING.) 

In  sluggish  cases  stimulating  applications  are  useful.  One 
like  the  following  may  be  selected : 

R;    Acidi  pyrogallici .^ss-j 

Petrolati aa  |ss.— M. 

SiG.— Apply  locally.  (Kaposi.) 

Treatment  by  the  .r-ray  has  been  followed  by  excellent 
results  in  some  very  obstinate  cases. 


526   DISEASES   OF   THE   SKIN  AND   ITS  APPENDAGES, 

LUPUS  VULGARIS* 

(Lupus  Exedens.) 

Definition. — A  local  manifestation  of  tuberculosis,  char- 
acterized by  soft  red  tubercles  that  usually  terminate  in 
ulceration  and  scarring. 

i^tiolog'y. — Early  life  and  female  sex  are  general  pre- 
disposing factors.  It  is  comparatively  rare  in  this  country, 
but  very  common  in  Austria  and  Germany.  The  exciting 
cause  is  the  tubercle  bacillus. 

Symptoms. — Lupus  vulgaris  most  frequently  manifests 
itself  on  the  face,  especially  near  the  nose.  It  begins  as 
minute,  deeply  seated,  reddish-brown  papules  which  grow 
very  slowly  until  they  reach  the  dimensions  of  tubercles. 
They  are  smooth,  quite  soft,  and  seldom  painful.  At  this 
stage  they  may  either  undergo  slow  absorption  or,  which  is 
more  frequent,  break  down  and  leave  chronic  ulcers.  The 
ulcers  are  shallow,  and  their  edges  are  soft  and  red.  There 
is  very  little  discharge.  They  spread  slowly,  and  may  in- 
volve all  the  soft  parts,  but  the  bone  is  never  invaded. 
While  one  part  of  the  ulcer  is  spreading,  other  parts  are 
being  filled  with  shriveled  cicatricial  tissue  which  in  turn  is 
often  the  seat  of  new  tuberculous  nodules. 

Diagnosis. — Epithelioma. — Epithelioma  is  a  disease  of 
advanced  life ;  it  begins  as  a  firm,  wax-like  nodule ;  the 
resulting  ulcer  starts  from  a  single  point ;  its  borders  are 
distinctly  elevated  and  hard ;  it  secretes  a  blood-streaked 
fluid  ;  and  it  is  often  painful. 

Syphilis. — The  age,  history,  associated  evidences  of  syph- 
iUs,  the  rapid  course,  the  deep  ulcers,  the  abundant  offensive 
discharge,  and  later  the  involvement  of  the  bones,  are  the 
diagnostic  features. 

Prognosis. — Very  guarded.  Its  removal  is  often  fol- 
lowed by  relapse. 

Treatment. — General  tonics,  like  iron,  arsenic,  phos- 
phorus, and  cod-liver  oil,  are  usually  indicated. 

Local  Treatment. — The  growth  may  be  removed  by  cauteri- 
zation, cureting,  excision,  or  electrolysis.  One  of  the  fol- 
lowing caustic  applications  may  be  employed : 


Or: 


SYPHILIS   CUTANEA.  52/ 

5t.    Acidi  salicylici ^ss-j 

CoUodii f|j-— M. 

R.    Acidi  pyrogallici      .^ij~''^j 

Vaselini  cerati  resinse  ...     aa  q.  s.  ad  5J. — M. 

(Stelwagon.) 


Often  the  best  results  are  obtained  by  cureting  and  sub- 
sequently applying  caustics. 

Both  phototherapy  and  x-ra.y  therapy  have  also  been  used 
with  considerable  success  in  the  treatment  of  lupus. 

SYPHILIS  CUTANEA^ 

The  secondary  symptoms  appear  between  the  first  and  the 
fourth  month  following  the  chancre,  and  are  characterized 
by  a  symmetric  arrangement,  a  coppery  color,  polymorphism 
(many  forms  at  the  same  time),  and  an  absence  of  itching. 
They  are  usually  associated  with  certain  general  symptoms, 
such  as  sore  throat,  pain  in  the  bones,  loss  of  hair,  enlarge- 
ment of  the  lymphatic  glands,  and  failure  of  health. 

The  tertiary  symptoms  appear  in  from  six  months  to  sev- 
eral years  after  the  primary  sore.  They  are,  as  a  rule, 
locahzed,  are  tubercular,  gummatous,  or  ulcerative  in  form, 
and  tend  to  group. 

Macular  Syphiloderm. — This  is  a  secondary  manifesta- 
tion, and  consists  in  a  general  eruption  of  dark-red  macules, 
varying  in  size  from  a  millet-seed  to  a  ten-cent  piece. 

Diagnosis. — Measles. — The  absence  of  fever,  of  catarrh,  of 
a  crescentic  arrangement,  together  with  the  history,  will  pre- 
vent an  error  in  diagnosis. 

Papular  Syphiloderm. — This  may  be  an  early  or  late 
manifestation,  and  is  characterized  by  a  general  eruption  of 
large  or  small,  dull-red  papules.  A  few  pustules  are  also 
frequently  present.  It  pursues  a  chronic  course,  finally  dis- 
appearing by  desquamation,  and  leaving  behind  slight  pig- 
mentation. 

Diagnosis. — The  history,  distribution,  dark  color,  and  the 
presence  of  pustules  will  separate  it  from  keratosis  pilaris, 
papular  eczema,  and  lichen  ruber. 


528   DISEASES   OF   THE   SKIN  AND   ITS  APPENDAGES. 

Tuberculous  Syphiloderm. — A  late  manifestation,  char- 
acterized by  a  localized  eruption  of  dark-red,  shiny  papules 
varying  in  size  from  a  pea  to  a  large  bean.  By  some  these 
tubercles  are  regarded  as  gummatous  in  character.  They 
pursue  a  chronic  course  and  finally  disappear  by  absorption 
or  ulceration.  The  ulcers  thus  formed,  when  single,  are 
round,  punched  out,  and  frequently  covered  with  crusts  ; 
when  they  coalesce,  they  form  a  serpiginous  sore  that  pours 
forth  a  thick  yellowish  discharge. 

Diagnosis. — Lupus  Vulgaris. — This  occurs  in  earlier  life; 
it  pursues  an  extremely  chronic  course ;  the  ulcer  is  super- 
ficial ;  the  tubercles  are  soft,  and  frequently  redevelop  in  the 
scar  tissue ;  the  secretion  is  scant ;  and  the  bone  is  never 
involved. 

Epithelioma. — In  this  affection  the  progress  is  slower; 
there  is  only  one  point  of  ulceration;  the  secretion  is  scanty; 
and  the  border  is  markedly  infiltrated. 

Bullous  Syphiloderm. — This  is  a  late  manifestation, 
and  is  characterized  by  an  eruption  of  well-filled  blebs  varying 
in  size  from  a  coffee-bean  to  a  walnut.  The  contents  of  the 
blebs  are  puriform.  They  subsequently  form  dark,  conic, 
stratified  crusts  under  which  are  ulcers  pouring  forth  a  thick, 
purulent  fluid. 

Diagnosis. — Pemphigus. — The  history,  the  concomitant 
symptoms  of  syphilis,  and  thick,  greenish  crusts  will  serve 
to  distinguish  syphilis  from  pemphigus. 

Gummatous  Syphiloderm. — This  appears  as  a  firm, 
circumscribed  nodule  that  gradually  turns  red  and  softens. 
It  may  disappear  by  absorption,  or  break  down  and  leave  a 
deep,  punched-out  ulcer. 

Moist  Papules  (Mucous  Patches). — These  consist  in 
soft  flat  papules  covered  with  an  offensive,  grayish  secretion. 
Heat  and  moisture  favor  their  development,  so  that  their 
favorite  seats  are  around  the  arms,  the  genitalia,  the  mouth, 
and  in  women  under  the  mammae. 

Papulosquamous  Syphiloderm. — This  may  be  an 
early  or  late  manifestation,  and  is  characterized  by  a  general 
eruption  of  small  papules  that  are  more  or  less  scaly,  so  as 
to  resemble  psoriasis. 


SYPHILIS   CUTANEA.  529 

Diagnosis.— The  history,  the  slight  scaling,  the  dirty-gray 
color  of  the  scales,  the  dark-red  color  of  the  lesions,  the 
especial  tendency  to  involve  the  palms  and  soles,  will  serve 
to  distinguish  syphilis  from  psoriasis. 

Squamous  l^C^ema. — In  this  affection  the  distribution, 
the  infiltration  of  the  skin,  and  the  marked  itching  will  lead 
to  a  correct  diagnosis. 

Annular  SypMloderm. — In  this  form  the  lesions  con- 
sist of  circles  or  semicircles  of  small,  dark-red  papules. 

Pustular  Syphiloderm. — This  form  usually  appears 
within  the  first  year,  and  is  characterized  by  a  general  erup- 
tion d-f  small  or  large,  acuminated  or  flat  pustules  that 
finally  dry  up  and  form  yellowish-brown  crusts.  Large 
lesions  leave  superficial  ulcers.  The  term  rupia  is  applied 
to  large,  conic,  stratified  crusts  that  rest  loosely  on  the  ulcer- 
ating basis. 

Diagnosis. —  Variola. — Absence  of  syphilitic  history,  the 
shot-like  feel,  the  umbilication,  the  itching,  the  high  fever, 
and  the  acute  course  will  separate  variola  from  syphilis. 

Acne. — This  is  usually  limited  to  the  face  and  shoulders  ; 
there  is  no  history  of  syphilis  or  concomitant  symptoms  of 
that  affection. 

Treatment. — The  internal  treatment  consists  in  the  admin- 
istration of  iodid  of  potassium,  mercurials,  and  tonics. 

R.    Hydrargyri  iodidi gr.  j 

Potassii  iodidi ^iv 

Syrupi  sarsaparillse  compositi 

Aquge aa  f^ij. — M. 

SiG.— Teaspoonful  three  times  a  day  after  meals. 

(R.  W.  Taylor.) 

Or: 

R  .    Hydrargyri  protiodidi gr.  v-x 

Extracti  opii gr.  iv. — M. 

Fiant  pilulse  No.  xx. 

SiG. — One  morning  and  evening.  (Hardaway.) 

Local  Treatment. — Papular  eruptions  may  be  washed  with 
mercurial  lotions ;  mucous  patches  may  be  dusted  with 
calomel ;  ulcers  may  be  dressed  with  iodoform. 

34 


530   DISEASES   OF  THE   SKIN  AND  ITS  APPENDAGES, 

LEPROSY. 

(Lepra;  Elephantiasis  GrsBcorum.) 

Definition. — A  chronic  contagious  disease,  excited  by 
the  bacillus  of  leprosy,  and  characterized  by  tubercular 
formations,  ulcerations,  atrophy,  disturbances  of  sensation, 
and  an  increase  or  decrease  of  pigment. 

l^tiologfy. — The  disease  is  contagious,  but  direct  inocula- 
tion is  essential  to  its  transmission.  It  seems  to  be  more 
common  in  hot  climates.  The  exciting  cause  is  the  Bacillus 
leprae,  which  closely  resembles  the  tubercle  bacillus. 

Varieties. — There  are  two  varieties  :  tubercular  leprosy 
and  anesthetic  leprosy ;  but  the  two  forms  are  often  asso- 
ciated in  the  same  patient. 

Symptoms. — Certain  prodromes  may  precede  the  out- 
break of  the  disease,  such  as  malaise,  headache,  chilliness, 
depression  of  spirits,  and  numbness  in  the  parts  to  be 
affected. 

Tiiberadar  Lepj^osy. — In  this  form  spots  of  erythema  ap- 
pear on  the  body ;  they  soon  become  pigmented  and  hyper- 
esthetic,  and  develop  into  tubercles  varying  in  size  from  a 
pea  to  a  walnut.  The  face,  extremities,  and  genitals  are  the 
parts  most  commonly  affected,  but  occasionally  the  mucous 
membranes,  especially  of  the  nose  and  throat,  are  invaded. 
Ultimately  the  tubercles  may  break  down  and  leave  super- 
ficial indolent  ulcers.  In  some  cases  a  bullous  eruption 
appears  from  time  to  time.  The  hair,  eyebrows,  and  eye- 
lashes fall  out,  the  eyes  become  inflamed,  the  features  dis- 
torted, and  the  voice  husky.  The  disease  may  last  many 
years,  death  finally  resulting  from  exhaustion  or  some  inter- 
current disease. 

Anesthetic  Leprosy. — In  this  form  the  peripheral  nerves 
are  invaded  by  the  Bacillus  leprae.  The  outbreak  may  be 
preceded  by  numbness,  itching,  or  lancinating  pains.  These 
symptoms  are  followed  by  the  appearance  of  discolored 
spots,  which  are  at  first  associated  with  hyperesthesia,  but 
later  more  or  less  anesthesia  develops.  The  skin  and  its 
appendages  atrophy,  the  bones  undergo  necrosis,  and  the 
phalanges  drop  off  one  by  one.    In  some  cases  (lepra  alba) 


EPITHELIOMA. 


:)j» 


the  skin  is  not  only  anesthetic,  but  distinctly  white.  Finally, 
when  the  nerves  are  more  or  less  destroyed,  paralysis  results. 
The  duration  is  many  years. 

Prognosis. — Unfavorable.  A  cure  is  practically  impos- 
sible, though  the  progress  of  the  disease  may  be  stayed  by 
appropriate  treatment. 

Treatment. — Sufferers  should  be  isolated.  Tonics  are 
usually  indicated,  Chaulmoogra  oil  and  gurjun  oil,  inter- 
nally and  externally,  have  been  highly  recommended.  Ex- 
ternally, chrysarobin,  ichthyol,  or  resorcin  may  be  applied 
to  the  affected  parts. 

EPITHELIOMA. 

(Skin  Cancer.) 

Ktiology. — Late  life,  heredity,  and  local  irritation  are  the 
predisposing  factors. 

Varieties. — Superficial,  deep-seated,  and  papillomatous. 

Superficial  Epithelioma  (Rodent  Ulcer). — This  form  usually 
begins  as  a  firm,  circumscribed,  reddish-yellow,  wax-like 
papule.  After  the  lapse  of  several  months  or  years  the 
papule  becomes  scaly,  and  the  removal  of  the  scales  is  fol- 
lowed by  a  slight  excoriation,  which  in  turn  becomes  covered 
with  a  slight,  reddish-brown  crust.  The  latter  tends  to 
adhere,  and  its  repeated  removal  is  followed  by  a  raw  surface, 
which  is  gradually  converted  into  an  ulcer.  The  ulcer  has 
a  prominent  indurated  margin  ;  its  outline  is  irregular ;  its 
base  is  uneven  and  glazed  ;  and  it  exudes  a  sanious,  viscid 
excretion.  It  is  not  painful ;  it  does  not  lead  to  enlargement 
of  the  neighboring  lymphatic  glands ;  nor  does  it  cause  im- 
pairment of  the  general  health.  It  spreads  very  slowly,  and 
sometimes  becomes  stationary  or  actually  heals.  More  fre- 
quently the  ulceration  continues  until  it  involves  all  the 
tissues  of  the  part,  even  the  bones.  The  ulcer  generally 
appears  on  the  face,  and  in  its  advance  it  may  destroy  the 
nose,  eyes,  or  a  large  portion  of  the  cranial  bones. 

Deep-seated  Epithelioma. — This  variety  may  begin  as  a 
deep-seated,  red,  shiny  tubercle,  or  it  may  develop  from  the 
superficial  form.     The  ulcer  which  is  ultimately  formed  is 


532    DISEASES   OF  THE   SKIN  AND   ITS  APPENDAGES. 

deep ;  its  base  is  granulaj- ;  its  edges  are  everted,  indurated, 
and  of  a  reddish-purple  color;  it  secretes  a  blood-stained 
yellow  fluid ;  it  is  the  seat  of  lancinating  pain ;  it  causes  en- 
largement of  the  neighboring  glands ;  and  it  sooner  or  later 
induces  the  cancerous  cachexia.  Death  may  result  from 
exhaustion,  or,  more  rarely,  from  hemorrhage  caused  by 
ulceration  of  a  large  blood-vessel. 

Papillomatous  Epithelioma. — This  may  begin  as  a  warty 
excrescence,  or  may  develop  from  one  of  the  preceding 
varieties.  It  is  characterized  by  an  ulcerated  surface  from 
which  springs  an  aggregation  of  large,  highly  vascular 
papillae.  Between  the  papillae  there  are  often  deep-seated 
fissures  from  which  exudes  an  offensive  viscid  discharge. 
The  general  health  is  impaired  and  the  neighboring  glands 
are  enlarged. 

Diagnosis. — Lupus  Vulgaris. — Lupus  begins  in  the 
young ;  the  original  papule  is  soft ;  there  is  often  more  than 
one  center  of  ulceration ;  the  margins  of  the  ulcer  are  not 
hard  and  everted ;  the  progress  is  extremely  slow ;  the  dis- 
charge from  the  ulcer  is  very  scant,  and  the  bones  are  never 
involved. 

Syphilis. — The  history,  the  associated  evidences  of  syphilis, 
the  rapid  progress  of  the  ulceration,  the  abundant  discharge, 
the  absence  of  pain,  and  the  effect  of  treatment  will  suggest 
the  diagnosis. 

Prognosis. — Guarded.  A  thorough  removal  in  the  be- 
ginning of  the  disease  is  often  followed  by  a  permanent  cure. 
When  the  process  is  advanced,  the  growth  usually  returns. 

Treatment. — Epitheliomatous  growths  may  be  removed 
by  the  use  of  caustics,  the  cautery,  the  curet,  or  by  excision. 
The  last  is  preferable  when  the  growth  is  small  and  circum- 
scribed. 

Phototherapy  and  .r-ray  therapy  have  recently  been  em- 
ployed with  considerable  success. 

AINHUM* 

Ainhum  is  a  rare  affection,  occurring  chiefly  in  the  colored 
race,  and  characterized  by  the  appearance  of  a  groove  or 


DERMA  TAL  GIA  -PR  URITUS.  1 3  3 

furrow  at  the  base  of  one  or  more  of  the  toes.  The  groove 
deepens,  the  affected  member  becomes  swollen,  and  finally 
drops  off  at  the  point  of  strangulation. 

DERMATALGIA* 

Dermatalgia,  or  neuralgia  of  the  skin,  is  a  rare  affection, 
and  is  characterized  by  paroxysms  of  sharp,  lancinating  pain 
in  the  skin,  which  arise  without  any  change  m  the  local 
appearance.  It  is  most  frequently  observed  in  women  of  a 
neuropathic  tendency,  and  may  arise  from  any  of  the  causes 
which  induce  neuralgia  elsewhere. 

Treatment. — The  cause  must  be  sought  for  and,  if  pos- 
sible, removed.  Tonics,  like  iron,  arsenic,  quinin,  and  phos- 
phorus, are  often  indicated.  Locally,  massage  and  electricity 
may  prove  useful. 

PRURITUS. 

Definition. — Pruritus  is  a  functional  affection,  character- 
ized by  itching  which  is  unassociated  with  any  objective 
phenomena. 

Ktiologfy. — Pruritus  may  arise  without  obvious  cause,  as 
the  pruritus  senilis  observed  in  the  old,  and  the  pruritus 
hiemalis  which  develops  on  the  approach  of  cold  weather 
and  disappears  when  the  weather  becomes  warm. 

Symptomatic  Pruritus. — Pruritus  may  be  a  symptom  of 
many  conditions,  notably  diabetes,  gout,  lithemia,  hysteria, 
neurasthenia,  and  Bright's  disease. 

Symptoms. — There  is  only  one  symptom,  and  that  is 
itching ;  but  as  a  result  of  scratching,  the  part  may  become 
hyperemic,  thickened,  or  the  seat  of  eczema. 

Diagnosis. — Pruritus  must  be  distinguished  from  the 
itching  induced  by  pediculosis,  or  some  local  disease,  like 
eczema. 

Prognosis. — This  will  depend  on  the  cause.  When  the 
primary  disease  is  curable,  the  prognosis  for  permanent 
relief  is  favorable.  In  other  cases  temporary  relief  only  is 
to  be  expected. 

Treatment. — Search  should  be  made  for  the  exciting 
cause,  which  should  be  removed,  if  possible.     In  all  cases 


534   DISEASES   OE  THE  SKIN  AND  ITS  APPENDAGES. 

the  urine  must  be  examined  for  sugar,  since  diabetes  is  one 
of  the  most  frequent  causes  of  pruritus.  Among  the  internal 
remedies  recommended  for  pruritus  may  be  mentioned  nux 
vomica,  belladonna,  and  pilocarpin.  The  best  local  remedies 
are  carbolic  acid,  vinegar,  thymol,  chloral-camphor,  boric 
acid,  resorcin,  menthol,  hydrocyanic  acid,  and  hot  water. 

R .    Resorcinolis gr.  xv-xxx 

Sodii  chloridi gr.  xv 

Glycerini f^ij 

Liquoris  calcis q.  s.  ad  f^iv. — M. 

(Hartzell.) 

R.    Acidi  carbolic! .5J~i'j 

Glycerini f^ij 

Alcoholis .  f^ij 

Aquge q.  s.  ad  Oj. — M. 

R.    Acidi  carbolic! gr.  xv 

Hydrargyr!  chloridi  mitis gr.  xx 

Unguent!  zinc!  oxidi ^j. 

SiG. — Apply  locally  in  pruritus  an!. 

TINEA  TRICHOPHYTINA. 

(Ringworm.) 

Definition. — A  contagious  disease  excited  by  a  vegetable 
parasite — the  trichophyton. 

Varieties. — On  the  scalp  it  is  termed  tmea  tonsurans ; 
on  the  body,  tinea  circinata ;  on  the  bearded  region,  tinea 
sycosis. 

TINEA  TONSURANS. 

This  form  is  observed  almost  exclusively  on  the  scalp  of 
children.  It  is  characterized  by  one  or  more  rounded,  scaly, 
elevated,  grayish-colored  patches  through  which  project  dry, 
brittle,  lusterless,  broken-off  hairs. 

Diagnosis. — Seborrhea. — The  patches  are  not  circum- 
scribed ;  the  scales  are  greasy ;  the  hair  is  not  involved ;  and 
the  microscope  reveals  no  parasite. 

Eczema. — The  patches  are  not  circumscribed  ;  the  hair  is 
not  involved  ;  there  is  more  inflammation ;  there  is  marked 
itching ;  and  the  microscope  reveals  no  parasite. 

Alopecia  Areata. — Baldness  is  complete ;  there  are  no 
scales ;  and  the  base  is  smooth  and  shiny. 


TINEA    CIRCFNATA.  535 

Prognosis. — Favorable. 

Treatment. — Tonics  are  often  indicated.  The  parts 
should  be  thoroughly  washed  with  soap  and  water,  and  the 
affected  hairs  removed.  The  following  parasiticides  may  be 
employed  in  ointment  or  lotion ;  mercury,  sulphur,  chrysa- 
robin,  or  sulphurous  acid. 

R ,    Hydrargyri  ammoniati ^j 

Petrolati ^j. 

SiG. — Apply  once  or  twice  daily. 

Or: 

R.     Betanaphtholis gi"-  xl 

Sulphuris  prsecipitati 3) 

Vaselini §j. — M. 

SiG. — Rub  into  affected  area  once  or  twice  daily. 

(Hardaway.) 

TINEA  CIRCINATA* 
(Ringworm  of  the  Body.) 

This  appears  as  one  or  more  rounded,  red,  shghtly  ele- 
vated scaly  patches,  which  on  close  examination  reveal 
minute  vesicles  or  papules.  As  the  disease  advances  new 
patches  spring  from  the  periphery,  while  the  central  portion 
clears  up.     There  is  often  considerable  itching. 

Diagnosis. — Psoriasis. — The  marked  scaling  ;  the  ab- 
sence of  itching ;  the  tendency  to  involve  the  extensor 
surfaces,  especially  the  knees  and  elbows  ;  and  the  absence 
of  the  trichophyton  will  separate  psoriasis  from  ringworm. 

Eczema. — The  patches  are  ill  defined ;  do  not  clear  in  the 
center ;  there  is  more  infiltration  of  the  skin ;  and  there  is 
no  trichophyton. 

Prognosis. — Favorable. 

Treatment. — Tonics  are  frequently  indicated  ;  mercury, 
sulphur,  sulphurous  acid,  and  hyposulphite  of  sodium  are 
among  the  best  parasiticides. 

R.    Sodii  hyposulphitis '  .    .    ^^ij 

Aquae f^ij. — M. 

SiG.— Apply  locally.  (Duhring.) 

Or: 

R-    Hydrargyri  ammoniati     . gr.  xxx 

Adipis ^j. — M. 

SiG. — Apply  locally. 


536    DISEASES   OF   THE   SKIN  AND   ITS  APPENDAGES. 

TINEA  SYCOSIS/ 

(Barber's  Itch;  Sycosis  Parasitica.) 

This  begins  as  a  red,  scaly  patch  involving  the  bearded 
region.  Soon  purplish  tubercles  and  pustules  form  around 
the  opening  of  the  hair-foUicles,  and  the  hairs  become  luster- 
less,  brittle,  and  loose.     There  is  often  considerable  itching. 

Diagnosis. — Simple  Sycosis. — In  this  the  inflammation  is 
superficial;  the  hairs  are  not  involved;  and  the  trichophyton 
is  absent. 

Eczema. — The  tubercles,  the  involvement  of  the  hairs,  and 
the  presence  of  the  trichophyton  will  separate  it  from  eczema. 

Prognosis. — Favorable;  unless  treated  actively,  however, 
there  may  be  a  permanent  loss  of  hair. 

Treatment. — The  affected  hairs  should  be  removed,  and 
one  of  the  following  parasiticides  employed  in  lotion  or  oint- 
ment :  mercury,  sulphur,  or  hyposulphite  of  sodium. 


Or: 


R.    Sodii  hyposulphitis "T^W] 

Aquae f^iij. — M. 

SiG. — Apply  locally. 

R.    Sulphuris  sublimati      ........    .^ij 

Vaselini .^ij. — M. 

SiG. — Apply  locally. 


TINEA  VERSICOLOR. 

(Pityriasis  Versicolor.) 

Definition. — A  chronic  affection  excited  by  a  vegetable 
parasite,  the  Microsporon  furfur,  and  characterized  by  fawn- 
colored  scaly  patches  which  usually  appear  about  the  chest. 

etiology. — It  is  a  disease  of  adult  life,  and  is  more  fre- 
quently observed  in  the  debilitated  and  uncleanly. 

Symptoms. — It  appears  usually  on  the  front  of  the  chest 
as  small  round  spots  of  a  pale-yellow  or  fawn  color,  which 
slowly  enlarge,  fuse,  and  form  slightly  elevated,  scaly  patches. 
Subjective  symptoms  are  generally  absent. 

Diagnosis. — Chloasma  somewhat  resembles  tinea  versi- 


TINEA   FAVOSA.  537 

color,  but  the  former  is  not  often  observed  on  the  trunk,  is 
not  scaly,  and  is  not  associated  with  a  parasite. 

Prognosis. — Favorable. 

Treatment. — The  parts  should  be  frequently  washed  with 
soap  and  water,  after  which  one  of  the  following  parasiticides 
may  be  applied:  Corrosive  sublimate  (2-3  grains  to  an  ounce 
of  water),  sulphurous  acid,  or  hyposulphite  of  sodium : 

R.    Sodii  hyposulphitis '7^\ 

Glycerini fj^iij 

Aquae q.  s.  ad  f^v. — M. 

SiG. — Apply  locally. 

Or: 

R.     Hydrargyri  chloridi  corrosivi      .    .    .    .    l^j 

Alcoholis f^iv 

Saponis  viridis      ^^ij 

Olei  lavandulae f^j. — M. 

SiG. — To  be  rubbed  in  well  night  and  morning. 

(Van  Harlingen.) 

TINEA  FAVOSA, 

(Favus.) 

Definition. — A  contagious  affection  of  the  scalp  excited 
by  the  Achorion  Schonleinii,  and  characterized  by  yellowish, 
cup-shaped  crusts. 

i^tiologfy. — It  is  observed  especially  in  poor,  ill-nourished 
children. 

Symptoms. — The  disease  is  characterized  by  one  or 
more  rounded,  yellow,  cup-shaped  crusts,  through  w^hich 
project  dry,  brittle,  lusterless  hairs.  The  underlying  tissue 
is  more  or  less  atrophied  and  scarred.  It  is  associated  with 
some  itching  and  a  peculiar  musty  odor. 

Diagnosis. — The  yellow,  cup-shaped  crusts,  the  odor, 
and  the  atrophy  of  the  skin  will  separate  it  from  ringworm. 

Prognosis. — Favorable.  When  not  treated  early,  it  may 
be  followed  by  permanent  baldness. 

Treatment. — The  crusts  should  be  removed  by  oil  or 
soap  and  water.  The  affected  hairs  should  also  be  removed. 
The  following  parasiticides  are  efficient :  mercuiy,  sulphur, 
chrysarobin,  and  hyposulphite  of  sodium. 


538    DISEASES   OF   THE   SKIN  AND   ITS  APPENDAGES. 

SCABIES. 

(Itch.) 

Definition. — Scabies  is  a  contagious  disease  excited  by 
an  animal  parasite — the  Acarus  scabiei — and  manifested  by 
papules,  vesicles,  pustules,  burrows,  and  intense  itching. 

Ktiology. — The  disease  is  always  acquired  through  inti- 
mate intercourse  with  patients  already  affected. 

Symptoms. — The  disease  manifests  itself  by  intense 
itching,  which  is  associated  with  an  eruption  of  small 
papules,  vesicles,  and  pustules.  Among  these  lesions  may 
be  found  cuniculi,  or  burrows ;  these  are  discolored,  dotted, 
slightly  elevated  lines,  ranging  from  a  line  to  half  an  inch  in 
length,  and  produced  by  the  penetration  of  the  female  acarus 
and  the  deposition  of  her  eggs  along  the  passage.  The 
parts  most  commonly  affected  are  the  hands,  between  the 
fingers,  the  wrists,  the  axillae,  the  genitalia,  beneath  the 
mammae,  and  the  inner  aspects  of  the  thighs.  The  face  and 
scalp  are  never  involved. 

Diagnosis. — The  recognition  of  scabies  rests  on  the 
history,  the  itching,  the  presence  of  burrows,  the  multi- 
formity of  the  lesions,  and  their  peculiar  distribution. 

Prognosis. — Favorable. 

Treatment. — Ointments  of  sulphur,  styrax,  and  naph- 
thol  are  efficient  remedies.  After  a  thorough  bath  the  whole 
body  should  be  anointed  twice  daily  for  three  or  four  days. 
At  the  end  of  this  time  the  bath  should  be  repeated,  and  the 
bed-linen  and  underclothing  changed.  The  infected  clothing 
should  be  sterilized. 

B.-    Sulphuris  sublimati ^J 

Balsami  Peruviani .^ss 

Adipis I    .    .  ^j. — M. 

SiG. — Rub  in  thoroughly  twice  daily.  (Duhring.) 

R.    Balsami  styracis ,^iv 

Adipis giss.— M. 


PEDICULOSIS. 


539 


PEDICULOSIS* 

(Phtheiriasis.) 

Pediculosis  Capitis. — This  form  results  from  the  pediculus 
capitis,  or  head-louse,  a  gray  insect  from  one  to  two  milli- 
meters in  length.  The  condition  is  recognized  by  itching  of 
the  scalp  and  the  discovery  of  the  lice  or  their  white  ova,  or 
nits.  Eczematous  lesions  resulting  from  scratching  are 
often  observed. 

Pediculosis  Corporis. — This  form  results  from  the  pediculus 
corporis,  pediculus  vestimenti,  or  body-louse,  a  somewhat 
larger  insect  than  the  head-louse.  The  condition  is  recog- 
nized by  intense  itching  on  the  covered  parts  of  the  body, 
scratch-marks,  petechiae  caused  by  the  bite  of  the  insect,  and 
the  discovery  of  the  lice  on  the  garments. 

Pediculosis  Pubis. — This  form  results  from  the  pediculus 
pubis,  or  crab-louse,  a  minute,  gray,  translucent  insect.  It 
is  found  on  parts  covered  with  short  hair,  as  the  pubes, 
axillae,  eyebrows,  etc. 

Treatment. — In  pediculosis  capitis  the  head  may  be 
thoroughly  washed  with  coal-oil,  dilute  carbolic  acid  (i  dram 
to  I  pint),  or  tincture  of  cocculus  indicus. 

In  pediculosis  corporis  the  parts  should  be  thoroughly 
washed  and  the  clothes  subjected  to  a  high  temperature. 
The  body  may  be  bathed  in  a  weak  solution  of  corrosive 
sublimate. 

In  pedicidosis  pubis  a  lotion  of  corrosive  sublimate  (2 
grains  to  I  ounce)  or  an  ointment  of  ammoniated  mercury 
(i  dram  to  i  ounce)  is  very  efficient. 


INDEX. 


Abdominal  distention,  27 

pain,  26 

reflex,  370 
Abscess  of  brain,  400 

of  liver,  107 

of  lung,  256 

retropharyngeal,  37 
Acetone,  tests  for,  127 
Acetonemia,  355 
Acetonuria,  127 
Acholia,  95 
Achylia  gastrica,  25 
Acid,  acetic,  test  for,  23 

butyric,  test  for,  23 

free,  test  for,  21 

HCl,  test  for,  qualitative,  21 
test  for,  quantitative,  22 

lactic,  test  for,  22 
Acidity  of  gastric  content,  25 
Acne,  9 1 

atrophica,  492 

hypertrophica,  492 

indurata,  492 

papulosa,  492 

pustulosa,  492 

rosacea,  493 

vulgaris,  490 
Acromegaly,  459 

Adams-Stokes  syndrome,  172,  192 
Addison's  disease,  161 
color  of  skin  in,  466 

keloid,  520 
Adenia,  160 
Agraphia,  motor,  401 
Ague,  294.     See  also  Malarial  fever. 
Ainhum,  530 
Alse  nasi,  respiratory  movements  of, 

199 
Albinism,  508 
Albumin,  tests  for,  126 


Albuminuria,  126 
Alcoholism,  461 

acute,  459 

chronic,  462 
Alexia,  402 
Alopecia,  510 

areata,  511 

circumscripta,  511 
Amoeba  coh,  74 
Amygdalitis,  31 

Amyotrophic  lateral  sclerosis,  414 
Analgesia,  371 
Anemia,  154 

cerebral,  389 

headache  of,  430 

lymphatic,  160 

pernicious,  155 

primary,  155,  157 

secondary,  155 

splenic,  160 
Anesthesia,  370 
Aneurysm  of  abdominal  aorta,  197 

of  aorta,  194 

thoracic,  195 
Aneurysmal  murmur,  171 
Angina  Ludovici,  36 

pectoris,  193 
false,  193 

simple,  35 
Anginoid  scarlet  fever,  303 
Angiocholitis,  catarrhal,  96 
Angioma,  523 

cavernosum,  523 

simplex,  523 
Angioneurotic  edema,  acute,  456 
Anhydremia,  151 
Anidrosis,  80 
Ankle-clonus,  369 
Ankylostomiasis,  86 
Annular  syphiloderm,  529 

541 


542 


INDEX. 


Anorexia,  19 

Anosmia,  199 

Anthrax,  494 

Anuria,  118 

Aorta,  abdominal,  aneurysm  of,  197 

aneurysms  of,  194 
Aortic  valves,  diseases  of,  182 
Apex-beat,  165 

changes  in  force  and  extent  of,  166 

displacement  of,  166 

palpation  of,  168 
Aphasia,  401 

ataxic,  401 

motor,  401 

sensory,  402  ■ 
Aphonia,  200 
Apoplexy,  cerebral,  390 

ingravescent,  392 

pulmonary,  241 
Appendicitis,  78 
Apraxia,  402 

Aran-Duchenne,  chronic  spinal  mus- 
cular atrophy  of,  411 
Argyll-Robertson  pupil,  377,  387 
Argyria,  467 
Arhythmia,  172 
Arm-jerk,  369 

Arm  or  leg,  temporary  spasm  of,  366 
Arteries,  cerebral,  obstruction  of,  395 
Arteriosclerosis,  197 
Arthritis  deformans,  350 

rheumatoid,  350 
Arthropathies,  374 
Articular  rheumatism,  acute,  339 

chronic,  343 
Artisans'  cramp,  453 
Ascaris  lumbricoides,  85 
Ascending  paralysis,  acute,  415 
Ascites,  115 
Asiatic  cholera,  331 
Asphyxia,  local,  456 
Astereognosis,  371,  402 
Asthma,  233 

essential,  233 

hay,  236 
Ataxia,  Friedreich's,  421 

hereditary,  421 

locomotor,  416 
Ataxic  gait,  368 

paraplegia,  419 
Atheroma,  197 


Athetosis,  367 
Atony  of  stomach,  45 
Atrophic  spinal  paralysis,  409 
Atrophy,  chronic  spinal  muscular,  411 

muscular,  373 

of  face,  unilateral  progressive,  458 

of  liver,  acute  yellow,  iii 

of  optic  nerve,  378 

progressive  muscular,  411 
Aural  vertigo,  434 
Auscultation  of  heart,  168 
Automatism,  epileptic,  436 

Babinski's  reflex,  369 

Bacilli,  tubercle,  in  sputum,  204 

Bacillus  tuberculosis,  258 

typhosus,  279 
Baldness,  510 
Banti's  disease,  161 
Barbadoes  leg,  521 
Barber's  itch,  536  ^ 

Barlow's  disease,  358 
Barrel-shaped  chest,  239 
Basedow's  disease,  162 
Basophiles,  149 
Bell's  mania,  379 

palsy,  427 
Bell-tympany,  271 
Berri-berri,  425 
Beta  oxybutyria,  127 
Bile,  tests  for,  in  urine,  129 
Bile-ducts,  catarrh  of,  96 
Black  vomit,  326 
Blaud's  pills,  158 
Blebs,  473  _ 
Bleeder's  disease,  359 
Blindness,  psychic,  402 

word-,  402 
Blisters,  fever-,  489 
Blood,  alkalinity  of,  147 

diseases  of,  145 

drying  and  staining  of,  150 

examination  of,  145 

in  pericardium,  179 

in  pernicious  anemia,  156 

parasites  in,  153 

specific  gravity  of,  146 
Blood-corpuscles,    red,    enumeration 
.  of,  147 

white,  enumeration  of,  148 
Blueness  of  skin,  467 


INDEX. 


543 


Boil,  494 

Bothriocephalus  latus,  85 

Bottger's  test  for  sugar  in  urine,  125 

Bowel,  paresis  of,  83 

Bradycardia,  172 

Brain,  abscess  of,  400 

congestion  of,  388 

disease,  organic,  headache  of,  429 

diseases  of,  380 

morbid  growths  in,  396 

tumors  of,  396 

water  on,  384 
Breakbone  fever,  336 
Breath,  fetor  of,  19 
Breathing,  amphoric,  211 

bronchial,  211 

bronchovesicular,  211 

cavernous,  211 

cogged-wheel,  212 

exaggerated,  211 

jerky,  212 

of  emphysema,  212 

puerile,  211 

tubular,  211 

vesicular,  211 

weak  or  shallow,  212 
Bright's  disease,  acute,  133 
Bromidrosis,  481 
Bronchi,  dilatation  of,  232 
Bronchiectasis,  232 
Bronchitis,  acute  catarrhal,  225 

capillary,  250 

chronic,  2  28 

croupous,  231 

fibrinous,  251 

pseudomembranous,  231 
Bronchophony,  212 
Bronchopneumonia,  250 
Bronchorrhagia,  240 
Brown-Sequard's  paralysis,  363 
Bruit  de  pot  fele  of  chest,  209 
Bulbar  paralysis,  414 

pseudo-,  415 
Bulimia,  19 
Bullae,  473 

Bullous  syphiloderm,  528 
Burns  and  scalds,  503 

Caisson  disease,  422 
Calculi,  biliary,  98 
pancreatic,  92 


Calculus,  renal,  141 
Callositas,  516 
Callus,  516 
Cancer  of  liver,  108 

of  pancreas,  90 

of  skin,  531 

of  stomach,  56 
Cancrum  oris,  30 
Capillary  nevus,  523 
Carbohydrates,  test  for,  24 
Carbunculus,  494 
Carcinoma  of  brain,  397 
Cardiac  murmur,  170 
Cardorespiratory  murmur,  170 
Carlsbad  salt,  artificial,  44 
Catalepsy,  376 
Catarrh,  acute  gastrie^  39 

autumnal,  236 

chronic  bronchial,  228 
gastric,  41 
nasal,  216 

epidemic,  322 

intestinal,  67 

of  bile-ducts,  96 
Catarrhal  fever,  322 
Causalgia,  372,  466 
Cephalalgia,  429 
Cephalodynia,  345 
Cerebral  anemia,  389 
headache  of,  430 

apoplexy,  390 

arteries,  obstruction  of,  395 

embolism,  395 

hemorrhage,  390 

hyperemia,  388 
headache  of,  429 

leptomeningitis,  acute,  380 
chronic,  382 

paralysis  in  children,  387 

rheumatism,  340 

thrombosis,  395 
Cerebrospinal  fever,  291 

sclerosis,  disseminated,  420 
Cervical    hypertrophic    pachymenin- 
gitis, 404 

muscles,  spasm  of,  366 
Cestodes,  84 
Chafing,  486 
Charcot-Leyden  crystals  in  sputum, 

204 
CharcoVs  hepatic  fever,  100 


544 


INDEX. 


Cheloid,  522 

Chest,  auscultation  of,  210 

barrel-shaped,  239 

cracked-pot  sound  of,  209 

dulness  or  flatness  of,  210 

emphysematous,  206 

expansion  of,  207 

hyperresonance  of,  209 

inspection  of,  205 

mensuration  of,  214 

normal  resonance  of,  209 

palpation  of,  207 

percussion  of,  208 

phthisinoid,  205 

pitch  of  note  in,  210 

prominences  and  depressions  of,  206 

rachitic,  205 

radioscopy  of,  214 

resistance  of,  210 

tympanitic  resonance  of,  209 
Cheyne-Stokes  breathing,  201 
Chicken-pox,  314 
Chilblain,  503 
Child-crowing,  223 
Chloasma,  514 
Chlorids  in  urine,  122 
Chlorosis,  157 
Cholecystitis,  acute,  97 
Cholelithiasis,  98 
Cholemia,  95 
Cholera,  331 

Asiatic,  331 

English,  77 

epidemic,  331 

infantum,  72 

malignant,  331 

morbus,  77 

nostras,  77 

sicca,  333 
Cholerine,  332  . 

Cholesteremia,  95 
Choluria,  129 
Chorea,  444 

Huntingdon's,  445 

insaniens,  446 
minor,  444 
Sydenham's,  444 
Choreiform  movements,  366 
Chromidrosis,  481 

Chronic  splenomegalic  polycythemia, 
161 


Chvostek's  phenomenon,  454 
Chyluria,  129 
Cirrhosis,  alcoholic,  103 

Laennec's,  103 

of  liver,  102 
atrophic,  102 
biliary,  106 
capsular,  106 
Hanot's,  105 
hypertrophic,  105 
syphilitic,  106 

of  lung,  255 

of  pancreas,  90 
Clavus,  517 

hysteric,  431,  440 
Colic,  26 

biliary,  99 

intestinal,  65 

pancreatic,  92 

renal,  142 
Color  of  skin,  464 
Coma,  375 
Comedo,  484 
Compensation    in    valvular    disease, 

182,  186 
Conception,  imperative,  379 
Confluent  smallpox,  310 
Congenital  myotonia,  455 
Congestion  of  brain,  388 

pulmonary,  242.     See  also  Lungs, 
congestion  of. 
•Consciousness,  disturbances  of,  375 
Constipation,  habitual,  63 
Constitutional  diseases,  339 
Consumption,  pulmonary,  257 
Convulsions,  364 

epileptiform,  364 

hysteroidal,  365 

local,  365 

salaam,  366 

tetanic,  365 
Corn,  517 

Cornu  cutaneum,  517 
Corrigan's  pulse,  174,  183 
Coryza,  215 
Cough,  202 

dry,  202 

laryngeal,  202 

moist  or  loose,  202 

winter,  228 
Croup  de  soleil,  460 


INDEX. 


545 


Cow-pox,  313 
Cramp,  artisans',  453 

writers',_  453 
Cremasteric  reflex,  370 
Crossed  paralysis,  428 
Croup,  catarrhal,  219 

false,  219 

spasmodic,  219 
Crusts,  478 

Curschmann's  spirals  or  sputum,  203 
Curving  of  nails,  468 
Cutaneous  emphysema,  468 

eruptions,  469 

horn,  517 
Cutis  pendula,  522 
Cyanosis,  general,  175 
Cyanotic  induration,  131 
Cyclic  albuminuria,  126 
Cylindroids,  123 
Cyst,  hydatid,  of  liver,  109 
Cyst  of  pancreas,  91 
Cytorrhyctes  variolse,  309 

Dandruff,  480 
Dandy  fever,  336 
Deafness,  378 

word-,  402 
Decubitus,  480 

acute,  374 

chronic,  374 
Degeneration,  reaction  of,  373 
Delirium,  379 

tremens,  462 
Delusion,  378 

fixed,  378 

hypochondriacal,  378 

of  grandeur,  378 

systematized,  378 

unsystematized,  378 
Dementia,  paretic,  385 
Demodex  folliculorum,  484 
Dengue,  336 
Dermatitis,  502 

calorica,  503 

contusiformis,  487 

exfoliativa,  504 

herpetiformis,  501 

medicamentosa,  503 

traumatic,  502 

venenata,  502 
Dermatolysis,  522 

35 


Diabetes,  353 

insipidus,  357 

mellitus,  353 

phosphaticus,  122 
Diacetic  acid,  test  for,  127 
Diaceturia,  127 
Diarrhea,  66,  67 
Diathesis,  hemorrhagic,  359 

uric  acid,  347 
Diazo-reaction,  129 
Dietl's  crises,  130 
Diffuse  erythema,  471 
Dilatation  of  stomach,  58 
Diphtheria,  315 

faucial,  316 

laryngeal,  316 

nasal,  317 
Diplegia,  facial,  362 
Discrete  smallpox,  309 
Disseminated  cerebrospinal  sclerosis, 

420 
Diver's  paralysis,  422 
Dizziness,  433 
Dobell's  solution,  37 
Dropsy,  175 

of  gall-bladder,  99 

of  pericardium,  179 
Dry  pleurisy,  266 
Duhring's  disease,  501 
Dura  mater,  hematoma  of,  383 
Dysentery,  73 
Dysidrosis,  513 
Dyspepsia,  catarrhal,  41 

nervous,  46 
Dysphagia,  19 
Dyspnea,  200 
Dystrophy,  muscular,  457 

Ear,  disturbances  of,  378 

noises  in,  378 
Echinococcus  of  liver,  109 
Eclampsia,  365 
Ecstasy,  376 
Ecthyma,  504 
Eczema,  497 

erythematosum,  497 

fissum,  498 

impetiginosum,  498 

madidans,  498 

papulosum,  497 

pustulosum,  498 


546 


INDEX. 


Eczema,  rubrum,  498 

seborrheal,  483 

squamosum,  498 

squamous,  529 

verrucosum,  498 

vesiculosum,  497 
Edema,  acute  angioneurotic,  456 

of  chest-walls,  208 

of  glottis,  224 

of  larynx,  224 

of  lungs,  244 
Egophony,  212 
Ehrlich's  diazo-reaction,  129 
Electromuscular  contractility,  changes 

in,_  373 
Elephantiasis,  521 

Arabum,  521 

Grascorum,  530 

pachydermia,  521 
Embolism,  cerebral,  395 
Embryocardia,  170 
Emesis,  20 
Emphysema,  cutaneous,  468 

hypertrophic,  238 

pulmonary,  236 
Empyema,  269 

Encephalitis,  suppurative,  400 
Endarteritis,  chronic,  197 
Endocarditis,  acute,  179 

chronic,  180 

ulcerative,  180 
Enlargement  of  superficial  veins,  466 
Enteralgia,  65 
Enteric  fever,  279.     See  also  Typhoid 

fever. 
Enteritis,  catarrhal,  67 
Enteroptosis,  61 
Enterorrhagia,  26 
Eosinophiles,  149 
Eosinophilia,  153 
Ephemeral  fever,  278 
Epidemic  catarrh,  322 

cholera,  331 

parotitis,  324 

roseola,  308 
Epilepsy,  435 

idiopathic,  435 

Jacksonian,  437 
Epileptic  automatism,  436 
Epileptiform  convulsions,  364 
Epistaxis,  200 


Epithelioma,  531 

deep-seated,  531 

papillomatous,  532 

superficial,  531 
Erb's  juvenile  dystrophy,  458 

phenomenon,  454 
Erysipelas,  319 

ambulans,  321 
Erythema,  diffuse,  471 

intertrigo,  486 

multiforme,  487 

nodosum,  487 

simplex,  486 
Erythroblasts,  152 
Esophagismus,  38 
Esophagus,  organic  obstruction  of,  38 

spasm  of,  38 

stenosis  of,  38 
Essential  vertigo,  434 
Estivo-autumnal  fever,  297 

parasite,  296 
Exhaustion,  heat-,  461 
Exocardial  murmur,  170 
Exophthalmic  goiter,  162 
Expectoration,  varieties  of,  202 
Eye,  disturbances  of,  377 
Eyeball,  tremor  of,  377 
Eyes,  conjugate  deviation  of,  377 

Face,  atrophy  of,  unilateral  proges- 
sive,  458 

spasm  of,  365 
Facial  diplegia,  362 

hemiatrophy,  458 

monoplegia,  362 

paralysis,  427 
Falling  sickness,  435 
Famine  fever,  289 
Faucial  diphtheria,  316 
Favus,  537 
Febricula,  278 
Feces,  impaction  of,  83 
Fehling's  test  for  sugar  in  urine,  125 

quantitative,  126 
Festination,  368 

in  paralysis  agitans,  452 
Fetor  of  breath,  19 
Fever,  273 

breakbone,  336 

catarrhal,  322 

causes,  275 


INDEX. 


547 


Fever,  cerebrospinal,  291 

Charcot's  hepatic,  100 

continued,  274 

dandy,  336 

degree  of,  274 

detection  of,  273 

effects  of,  on  tissues,  275 

enteric,    279.     See    also    Typhoid 
jever. 

ephemeral,.  278 

estivo-autumnal,  297 

famine,  289 

intermittent,  274 

jail,  287 

lung,  245 

malarial,   294.     See  also  Malarial 
fever. 

period  of  incubation  in,  276 

quartan,  295 
double,  296 

quotidian,  295 

rashes  in,  date  of  appearance,  277 

relasping,  289 

remissions  of,  274 

remittent,  274,  297 

rheumatic,  339 

scarlet,  301 

semitertian,  297 

ship,  287 

simple  continued,  278 

spirillum,  289 

spotted,  291 

stages  of,  273 

symptoms,  275 

termination  by  crisis,  278 

terminations  of,  274 

tertian,  295 

thermic,  460 

treatment,  275 

types  of,  274 

typhoid,    279.     See   also    Typhoid 
fever. 

typhus,  287 

yellow,  325 
Fever -blisters,  489 
Fiber,  elastic,  in  sputum,  203 
Fibrinous  pleurisy,  266 
Fibroma,  523 

Filaria  sanguinis  hominis,  87 
Fish-skin  disease,  519 
Fleischl's  hemoglobinometer,  146 


Flint  murmur,  183 
Floating  kidney,  130 
Folliculitis  barbce,  510 
Foot,  perforating  ulcer  of,  374,  480 
Fowler's  test  for  urea,  119 
Freckle,  514 
Fremitus,  208 
Friedreich's  ataxia,  421 
Functional     diseases     of     sebaceous 
glands,  482 
nervous  diseases,  429 
Furunculus,  494 

Gabbett's  method  for  demonstrating 
tubercle  bacilli  in  sputum,  204 
Gait,  368 

ataxic,  368 

of  pseudomucsular  hypertrophy,368 

spastic,  368 

steppage,  368,  426 
Gall-bladder,  dropsy  of,  99 
Gall-stones,  98 
Gangrene  of  lungs,  256 

symmetric,  374,  455 
Gastralgia,  50 
Gastrectasis,  58 
Gastric  catarrh,  acute,  39 
chronic,  41 

contents,  acidity  of,  25 
normal,  25 
examination  of,  21 
Gastritis,  acute,  39 

chronic^  41 
Gastrodynia,  50 
Gastroptosis,  61 
Gastrorrhagia,  62 
Gastrosuccorrhea,  49 
General  paralysis  of  insane,  385 

paresis,  385 
German  measles,  308 
Giant  urticaria,  488 
Giddiness,  433 
Gin-drinker's  liver,  103 
Girdle  pain,  406,  408 

sensation,  372 
Glenard's  disease,  61 
Glioma  of  brain,  397 
Globus  hystericus,  365 
Glossy  skin,  375,  424,  467,  509 
Glottis,  edema  of,  224 

spasm  of,  223 


548 


INDEX. 


Glucose  in  urine,  tests  for,  124 

Gluteal  reflex,  370 

Glycosuria,  123 

Gmelin's  test  for  bile  in  urine,  129 

Goiter,  exophthalmic,  162 

Gout,  346 

acute,  347 

chronic,-  347 

latent,  347 

non-articular,  347 

retrocedent,  347 

rheumatic,  350 
Goutiness,  347 

Gowers'  hemoglobinometer,  145 
Graefe's  sign,  162 
Graphospasm,  451 
Gravel,  141 
Graves'  disease,  162 
Green  sickness,  157 
Grutum,  485 

Gummatous  syphiloderm,  528 
Gums,  17 

Hair  and  nails,  trophic  affections  of, 

375. 
Hallucination,  379 
Hand,  spasm  of,  366 
Hanot's  hypertrophic  cirrhosis,  105 
Hardness  of  skin,  467 
Hay-fever,  236 

Hay's  test  for  bile  in  urine,  129 
Head,  swimming  in,  433 
Headache,  429 

hysteric,  431 

of  cerebral  anemia,  430 
hyperemia,  429 

of  organic  brain  disease,  429 

reflex,  430 

sick-,  450 

toxemic,  430 
Hearing,  hyperacusis  of,  378 
Heart,  auscultation  of,  169 

chronic  valvular  disease  of,  182 

enlargement  of,  189 

fatty  degeneration  of,  191 
infiltration  of,  191 

fibroid  induration  of,  191 

hypertrophy  of,  189 

neuralgia  of,  193 

palpation  of,  168 

palpitation  of,  174 


Heart,  percussion  of,  168 
Heart-block,  172 
Heart-sounds,  adventitious,  170 

alteration  in  rhythm  of,  169 

intensity  of,  169 
Heat-exhaustion,  461 
Heat-stroke,  460 
Heberden's  nodes,  351 
Heller's  test  for  albumin  in  urine,  126 

for  blood  in  urine,  128 
Hematemesis,  20,  62 
Hematoma  of  dura  mater,  383 
Hematomyelitis,  406 
Hematoporphyrinuria,  124 
Hematuria,  127 
Hemianesthesia,  370 
Hemiatrophy,  facial,  456 
Hemic  murmur,  171 
Hemicrania,  450 
Hemiplegia,  361,  362 
Heniocytometer,  Thoma-Zeiss,   147 
Hemoglobin,  estimation  of,  145 
Hemoglobinometer,  Fleischl's,  146 

Gowers',  145 
Hemoglobinuria,  128 
Hemopericardium,  179 
Hemophilia,  359 
Hemoptysis,  240 
Hemorrhage,  bronchopulmonary,  240 

cerebral,  390 

into  pancreas,  88 
Hemorrhagic  diathesis,  359 

macules,  470 

measles,  306 

pachymeningitis,  383 

pleurisy,  266,  272 

purpura,  360 

urticaria,  488 
Hemothorax,  272 
Hepatargy,  95 

Hepatic  fever,  Charcot's,  100 
Hepatitis,  acute  parenchymatous,  1 1 1 
suppurative,  107 

catarrhal,  96 

chronic  interstitial,  102 
Hereditary  ataxia,  421 
Herpes  facialis,  490 

gestationis,  501 

iris,  491 

progenitalis,  490 

simplex,  489 


INDEX. 


549 


Herpes  zoster,  490 
Hiccup,  25 

Hippocratic  succussion,  214,  271 
Hirsuties,  520 
Hives,  488 

Hob-nailed  liver,  103 
Hodgkin's  disease,  160 
Horn,  cutaneous,  517 
Huntingdon's  chorea,  445 
Hutchinson's  teeth,  17 
Hydatid  cyst  of  liver,  log 
Hydremia,  151 
Hydrocephalus,  chronic,  384 

congenital,  internal,  384 

spurious,  71 
Hydronephrosis,  143 
Hydropericardium,  179 
Hydrophobia,  337 
Hydrops  vesicae  fellas,  99 
Hydrothorax,  270 
Hyperacidity,  25 

of  gastric  contents,  48 
Hyperacusis  of  hearing,  378 
Hyperchlorhydria,  25,  48 
Hyperemia,  cerebral,  3S8 
headache  of,  427 

of  kidneys,  131 

of  liver,  10 1 
Hyperesthesia,  372 
Hyperidrosis,  480 
Hyperosmia,  199 
Hypertrichosis,  520 
Hypertrophy  of  heart,  189 

of  tonsils,  34 

pseudomuscular,  457 
Hypochylia  gastrica,  25 
Hypoleukocytosis,  153 
Hypotonia,  414 
Hysteria,  439 
Hysteric  clavus,  431,  440 

headache,  431 

ischemia,  440 
Hysteroidal  convulsions,  365 

Ichthyosis,  519 
Icerus,  94 

neonatorum,  95 
Idiopathic  epilepsy,  435 
Ileocolitis,  acute,  71 
Ileus,  81 

gall-stone,  83 


Illusion,  379 

Imperative  conception,  379 
Impetigo  contagiosa,  506 
Impulse,  morbid.  379 
Indican,  tests  for,  128 
Indicanuria,  128 
Induration,  cyanotic,  131 

of  skin,  467 
Inebriety,  461 
Infantile  paralysis,  409 
Infectious  diseases,  acute,  273 
jaundice  in,  278 
period  of  incubation  in,  276 
protection  from  future  attacks 

in,  277 
rashes  in,  date  of  appearance, 
277 
Inflammation  of  skin^  471 
Inflammatory  diseases  of  skin,  486 

rheumatism,  339 
Influenza,  322 

Insane,  general  paralysis  of,  385 
Isolation,  460 
Insular  sclerosis,  420 
Intercostal  neuralgia,  447 
Intermittent  tetanus,  454 
Intestinal  catarrh,  67 

colic,  65 

obstruction,  81 
Intoxications,  457 
Intussusception,  intestinal,  82 
Invagination,  intestinal,  82 
Ischemia,  hysteric,  440 
Itch,  538 

barber's,  536 

Jacksonian  epilepsy,  437 
Jail  fever,  287 
Jaundice,  94 

catarrhal,  96 

malignant,  iii 
Jaw-jerk,  369 

Johnson's  test  for  albumin  in  urine, 
126 

Kakke,  425 
Kelis,  522 
Keloid,  522 

Addison's,  520 
Keratoma,  516 
Keratosis  pilaris,  515 


S^o 


IMJDEX. 


Kernig's  sign,  291,  369 

Kidney,  amyloid  degeneration  of,  139 

contracted  or  gouty,  137 

floating,  130 

hyperemia  of,  131 

lardaceous,  139 

large  white,  135 

red  granular,  137 

tuberculosis  of,  144 

waxy,  139 
Kleptomania,  379 
Knee-jerk,  368 
Koplik's  sign,  306 

Labyrinthine  vertigo,  434 
Laennec's  cirrhosis,  103 
La  grippe,  322 
Landry's  disease,  415 
Landouzy-Dejerine    type    of    dystro- 
phy, 4  8 
Laryngeal  diphtheria,  316 
Laryngismus  stridulus,  223 
Laryngitis,  acute  catarrhal,  218 

chronic,  221 

syphilitic,  222 

tuberculous,  221 
Laryngospasmus,  223 
Larynx,  200 

edema  of,  224 
Latent  gout,  347 
Lead-poisoning,  chronic,  464 
Leg  or  arm,  temporary  spasm  of,  366 
Legal' s  test" for  acetone  in  urine,  127 
Lentigo,  514 
Lepra,  5  o 

alba,  530 
Leprosy,  530 
Leptomeningitis,  acute  cerebral,  380 

chronic  cerebral,  382 

spinal,  403 
Leucinuria,  120 
Leukemia,  158 
Leukocythemia,  158 
Leukocytosis,  152 
Leukoderma,  508 
Leukopenia,  153 
Leukoplakia  buccalis,  18 
Lichen  pilaris,  513 

planus,  450 

ruber,  450 

scrofulosus,  450 


Lightning  pains,  37:2 

Lipemia,  153 

Lithemia,  34 

Lithuria,  119 

Litten's  diaphragm  phenomenon,  207 

Little's  disease,  388 

Liver,  abscess  of,  107 

acute  yellow  atrophy  of,  iii 

amyloid,  no 

area  of  dulness  in,  92 

cancer  of,  108 

cirrhosis  of,  102 
atrophic,  102 
biliary,  106 
capsular,  106 
Hanot's,  105 
hypertrophic,  105 
syphilitic,  106 

echinococcus  of,  109 

gin-drinker's,  103 

hob-nailed,  103 

hydatid  cyst  of,  109 

hyperemia  of,  10 1 

irregularities  of,  93 

lardaceous,  no 

palpation  of,  92 

percussion  of,  93 

waxy,  no 
Lock-jaw,  335 
Locomotor  ataxia,  416 
Lumbago,  344 
Lung  fever,  245 
Lungs,  abscess  of,  256 

cirrhosis  of,  255 

congestion  of,  active,  242 
hypostatic,  243 
passive,  242 

edema  of,  244 

gangrene  of,  256 

hemorrhagic  infarct  of,  241 

splenization  of,  243 
Lupus  erythematosus,  524 

exedens,  526 

vulgaris,  526 
Lymphadenitis,  retropharyngeal,  37 
Lymphadenoma,  general,  160 
Lymphatic  leukemia,  159 
Lymphocytes,  148 
Lymph-scrotum,  521 

Macrocytosis,  152 


INDEX. 


551 


Macular  syphiloderm,  527 
Macules,  469 

brown,  471 

hemorrhagic,  470 

red,  469 

white,  471 

yellow,  471 
Malarial  cachexia,  chronic,  298 

fever,  294 

intermittent,  297 
pernicious,  298 
Malignant  cholera,  331 

measles,  306 

scarlet  fever,  303 

smallpox,  311 
Mania,  379 
Marie's  disease,  457 
Mast-cells,  149 
Measles,  305 

German,  308 

malignant,  306 
Megrim,  450 
Melanemia,  151 
Melena,  26 

Meniere's  disease,  434 
Meningitis,    epidemic    cerebrospinal, 
291 

spinal,  403 
Meningo-encephalitis,  chronic,  385 
Merycismus,  25 
Microcytosis,  152 
Migraine,  450 
Miliaria,  507 
Milium,  485 

Mitral  valve,  diseases  of,  184,  185 
Mobius'  sign,  162 
Moist  papules,  528 
Mole,  51S 
Molluscum  contagiosum,  515 

epitheliale,  515 

fibrosum,  523 

sebaceum,  515 
Monanesthesia,  371 
Monoplegia,  361,  362 

facial,  362 
Morbid  growths  in  brain,  396 

impulse,  379 
Morbilli,  305 

Morbus  maculosus  Werlhofii,  360 
Morphea,  520 
Morphinomania,  464 


Morvan's  disease,  422 
Mother's  mark,  523 
Motion,  disturbances  of,  361 
Mucin,  spirals  of,  in  sputum,  203 
Mucous  membranes,  rheumatic  affec- 
tions of,  345 

patches,  528 
Muguet,  29 
Multiple  neuritis,  325 

sclerosis,  420 
Mumps,  324 

Murexid  test  for  uric  acid,  119 
Murmur,  aneurysmal,  171 

cardiac,  170 

exocardial,  170 

Flint,  183 

hemic,  171 
Muscles,  diseases  of,  380 
Muscular  atrophy,  373 
chronic  spinal,  411 
progressive,  411 

dystrophy,  457 

rheumatism,  344 

sense,  373 
Myalgia,  344 
Myasthenia  gastrica,  45 
Mydriasis,  377 
Myelitis,  acute,  405 

central,  405 

chronic,  408 

diffuse,  405 

transverse,  405 
Myelocytes,  149 
Myelogenous  leukemia,  159 
Myocarditis,  acute,  190 
Myocardium,  diseases  of,  191 
Myodynia,  344 
Myosis,  377 

Myotonia,  congenital,  454 
Myxedema,  163 

Nevus,  capillary,  523 

lipomatodes,  519 

pigmentosus,  518 

pilosus,  519 

spilus,  519 

vasculosis,  523 

verrucosus,  519 
Nails,  abnormal  conditions  of,  468 

and  hair,  trophic  affections  of,  375 

atrophy  of,  468 


552 


INDEX. 


Nails,  curving  of,  468 
Nasal  diphtheria,  317 
Nematodes,  85 
Nephritis,  acute,  133 

chronic  interstitial,  137 

parenchymatous,  135 
Nephrolithiasis,  141 
Nephroptosis,  130 
Nerves,  diseases  of,  380,  423 
Nervous  diseases,  functional,  429 

prostration,  442 

system,  diseases  of,  361 
Nettlerash,  488 
Neuralgia,  372,  446 

intercostal,  447 

occipital,  447 

of  heart,  193 

of  stomach,  50 

trifacial,  447 
Neurasthenia,  442 

gastrica,  46 
Neuritis,  423 

multiple,  425 

optic,  378 
Neuromimesis,  438 
Neutrophiles  polymorphonuclear,  149 
Nevus.     See  Ncevus. 
Niemeyer's  pill  for  cirrhosis  of  liver, 

105 
Nigrities,  18 

Nodes,  Heberden's,  351 

Noises  in  ear,  378 

Noma,  30 

Nose,  199 

Nutrition,  disturbances  of,  373 

Nystagmus,  377 

Occipital  neuralgia,  ^47 

Oligochromemia,  153 

Oligocythemia,  154 

Onychia,  469 

Opisthotonos,  335 

Opium  poisoning,  chronic,  464 

Optic  nerve,  atrophy  of,  378 

neuritis,  377 
Orthostatic  albuminuria,  126 
Osmidrosis,  481 
Oxaluria,  122 
Oxyuris  vermicularis,  86 


Pachyacria, 


459 


Pachydermatocele,  522 
Pachymeningitis,    cervical    hypertM. 
phic,  404 

chronic,  383 
spinal,  404 

hemorrhagic,  383 

internal,  404 
Pallor,  466 

Palpation  of  heart,  168 
Palpitation,  175 
Palsy,  Bell's,  427 

scriveners'  453 

shaking,  451 
Paludism,  294.     See     also    Malarial 

fever. 
Pancreas,  calculi  of,  92 

cancer  of,  90 

cirrhosis  of,  90 

cysts  of,  91 

hemorrhage  into,  88 
Pancreatitis,  acute,  89 

chronic,  90 
Papillitis,  377 

Papillomatous  epithelioma,  532 
Papular  syphiloderm,  527 
Papules,  473 

moist,  528 
Papulosquamous  syphiloderm,  528 
Paracentesis  abdominis,  117 
pericardii,  178 

for  pleurisy,  269 
Paralysis,  361 

acute  ascending,  415 

agitans,  451 

atrophic  spinal,  409 

Brown-Sequard's,  363 

bulbar,  414 

cerebral,  in  children,  387 

crossed,  428 

divers',  422 

facial,  427 

general,  of  insane,  385 

infantile,  409 

irregular,  361 

postdiphtheric,  317 

spastic  of  infants,  387 
Paramyoclonus  multiplex,  367 
Parenesthesia,  371 
Paraphasia,  401 
Paraplegia,  361,  363 

ataxic,  419 


INDEX. 


53 


Paraplegia,  primary  spastic,  413 
Parasite,  animal,  84 

estivo-autumnal,  296 

in  blood,  153 

quartan,  295 

tertian,  295 
Paresis,  general,  385 

of  bowel,  83 
Paresthesia,  372 
Paretic  dementia,  385 
Parkinson's  disease,  451 
Parosmia,  199 
Parotitis,  epidemic,  324 
Parry's  disease,  162 
Patellar  tendon  reflex,  368 
Pectoriloquy,  212 
Pediculosis,  539 

capitis,  539 

corporis,  539 

pubis,  539 
Pemphigus,  505" 

foliaceus,  505 

vulgaris,  505 
Pepsin,  test  for,  23 
Peptic  ulcer,  52 
Percussion  of  heart,  168 
Perforating  ulcer  of  foot,  374,  480 
Pericarditis,  176 
Pericardium,  air  in,  179 

blood  in,  179 

dropsy  of,  179 
Perihepatitis,  chronic,  106 
Peritonitis,  acute,  112 

chronic  diffuse,  114 
Perityphlitis,  78 
Pernio,  501 
Pertussis,  329 
Petechiae,  470 

Pettenkofer's  test  for  bile  in  urine,  129 
Pharyngitis,  acute,  35 

chronic,  36 
Phenylhydrazin  test  for  sugar  in  urine, 

125 
Phosphaturia,  121 
Phtheiriasis,  539 
Phthisis,  257 

acute,  261 

chronic  ulcerative,  259 

fibroid,  261 
Pica,  19 
Pin-worm,  86 


Pityriasis  versicolor,  536 

Plantar  reflex,  370 

Plethora,  151 

Pleura,  diseases  of,  265 

Pleural  thickening,  chronic,  266 

Pleurisy,  265 

dry,  266 

fibrinous,  266 

hemorrhagic,  266,  272 

latent,  267 

purulent,  266 

sacculated,  266 

serofibrinous,  266 
Pleuritis,  265 
Pleurodynia,  344 
Plumbism,  464 
Pneumohydrothorax,  271 
Pneumonia,  alcoholic,  248 

catarrhal,  250 

central,  248 

chronic,  255 
interstitial,  255 

croupous,  245 

hypostatic,  243 

in  children,  247 

lobar,  245 

lobular,  250 

massive,  248 

migratory,  248 

senile,  247 

typhoid,  247 
Pneumonitis,  245 
Pneumopericardium,  179 
Pneumopyothorax,  271 
Pneumothorax,  270 
Podagra,  346 
Poikilocytosis,  152 
Points  douloureux,  372 
Poisoning,  chronic  lead-,  464 
opium-,  464 

rhus-,  502 
Poliomyelitis,  acute  anterior,  409 

chronic  anterior,  411 
Polycythemia,  151 

chronic  splenomegalic,  161 
Polyuria,  118 
Pomphi,  477 
Pompholyx,  513 
Port-wine  mark,  523 
Postdiphtheric  paralysis,  317 
Precordium,  prominence  of,  167 


554 


INDEX, 


Pressure  sense,  373 

Prickly  heat,  507 

Progressive  muscular  atrophy,  411 

Prosopalgia,  446 

Prostration,  nervous,  442 

Prurigo,  500 

Pruritus,  533 

hiemalis,  533 

senilis,  533 
Pseudo-angina  pectoris,  193 
Pseudo-bulbar  paralysis,  412 
Pseudoleukemia,  160 
Pseudomuscular  hypertrophy,  457 
Psoriasis,  495 
Psychic  blindness,  402 

deafness,  401 

disturbances,  378 
Ptyalism,  31 

Pulmonary  valve,  disease  of,  186 
Pulsation,  abnormal  centers  of,  167 
Pulse,  171 

asymmetric  radial,  174 

bigeminal,  172 

capillary,  174 

Corrigan's,  174,  183 

dicrotic,  173 

high-tension,  173 

increased  frequency  of,  171 

infrequency  of,  172 

intermittent,  172 

irregular  rhythm  of,  172 

low-tension,  174 

paradoxic,  173 

tardy,  183 

trigeminal,  172 

venous,  174 

water-hammer,  174,  183 
Pulse-temperature  ratio,  275 
Pulsus  paradoxus,  173 

tardus,  183 
Puncture,  Quincke's,  385 
Pupil,  Argyll-Robertson,  377,  387,417 
Pupils,  inequality  of,  377 
Purpura  hemorrhagica,  360 
Purpuric  spots,  470 
Purulent  pleurisy,  266 
Pustular  syphiloderm,  529 
Pustules,  474 
Pyelitis,  139 
Pyelonephritis,  140 
Pylorus,  stenosis  of,  58 


Pyonephrosis,  140 
Pyothorax,  269 
Pyromania,  379 
Pyuria,  129 

Quartan  fever,  295 
double,  296 
parasite,  295 
Quincke's  puncture,  385 
Quotidian  fever,  295 

Rabies,  337 

Rachitic  rosary,  352 

Rachitis,  352 

Rales,  208,  213 

Raynaud's  disease,  374,  455 

Reaction  of  degeneration,  373 

Reflex,  abdominal,  370 

ankle,  369 

arm,  369 

Babinski's,  369 

cremasteric,  370 

cutaneous,  370 

gluteal,  370 

headache,  430 

jaw,  369 

patellar  tendon,  368 

plantar,  370 
Reflexes,  368 

superficial,  369 
Reichmann's  disease,  49 
Relapsing  fever,  289 
Rennet,  test  for,  23 

zymogen,  test  for,  23 
Respiration,  200 

Cheyne-Stokes,  201 

normal,  201 
Retardation  of  sensations,  371 
Retrocedent  gout,  347 
Retropharyngeal  abscess,  37 

lymphadenitis,  37 
Retropulsion  in  paralysis  agitans,  452 
Rheumatic  affections  of  mucous  mem- 
branes, 345 
of  serous  membranes,  345 

fever,  339 

gout,  350 
Rheumatism,  articular,  acute,  339 
chronic,  343 

cerebral,  340 

inflammatory,  339 


INDEX. 


555 


Rheumatism,  muscular,  344 

other  manifestations  of,  344 
Rheumatoid  arthritis,  350 
Rhinitis,  acute,  215 

chronic,  216 
Rhus  diversiloba,  502 

toxicodendron,  502 

venenata,  502 
Rhus-poisoriing,  502 
Rickets,  352 
Ringworm,  534 

of  body,  535 
Risus  sardonicus,  335 
Roberts's  test  for  albumin  in  urine, 

127 
Rodent  ulcer,  531 
Romberg's  symptom,  417 
Rose-cold,  236 
Roseola,  epidemic,  308 
Rotheln,  308 
Round-worms,  85 
Rubella,  308 

morbilliform,  308 

scarlatiniforme,  308 
Rubeola,  305 
Rumination,  25 
Rupia,  529 

Sacculated  pleurisy,  266 
Salaam  convulsions,  366 
Saltatory  spasm,  366 
Sarcoma  of  brain,  397 
Saturnism,  464 
Scabies,  538 
Scalds,  503 
Scales,  478 
Scarlatina,  301 
Scarlet  fever,  301 
anginoid,  303 
malignant,  303 
Sciatica,  426 
Sclerema,  520 
Scleriasis,  520 
Scleroderma,  518 
Sclerosis,  amyotrophic  lateral,  414 

anterolateral,  413 

disseminated  cerebrospinal,  420 

insular,  420 

lateral,  413 

multiple,  420 

posterior  spinal,  416 


Scorbutus,  358 

Scriveners'  palsy,  453 

Scrotum,  lymph-,  521 

Scurvy,  358 

Seat-worm,  86 

Sebaceous  glands,  functional  diseases 

of,  482 
Seborrhea,  482 
Seborrheal  eczema,  483 
Seborrhoea  congestiva,  524 

oleosa,  483 

sicca,  482 
Sensation,  disturbances  of,  370 

girdle,  372 

retardation  of,  372 
Septicemia,  typhoid,  280 
Serofibrinous  pleurisy,  266 
Serous  membranes,  rheumatic  affec- 
tions of,  345 
Shaking  palsy,  451 
Shingles,  490 
Ship  fever,  287 
Sick-headache,  450 
Sickness,  falling,  435 
Singultus,  25 

Skin    and   appendages,   diseases    of, 
466 

blueness  of,  467 

cancer,  531 

color  of,  466 

in  Addison's  disease,  466 

glossy,  424,  467,  509 

gray  discoloration  of,  465 

hardness  of,  467 

induration  of,  467 

inflammation  of,  471 

inflammatory  diseases  of,  486 

trophic  affections  of,  375 

yellowness  of,  466 
Skoda's  resonance,  267 
Smallpox,  308 

confluent,  310 

discrete,  309 

malignant,  311 
Smell,  sense  of,  acuteness  of,  199 
impairment  or  loss  of,  199 
perversions  of,  199 
Somnambulism,  376 
Sore  throat,  acute,  35 
Southey's  tubes,  135 
Space,  sense  of,  372 


556 


INDEX. 


Spasm,  364,  365 

laryngeal,  200 

of  cervical  muscles,  366. 

of  esophagus,  38 

of  face,  365 

of  glottis,  223 

of  hand,  366 

saltatory,  366 

temporary,  of  arm  or  leg,  366 
Spastic  gait,  368 

paralysis  of  infants,  387 

paraplegia,  primary,  413 
Sphygmogram  of  dicrotic  pulse,  173 

of  trigeminal  pulse,  173 
Spinal  cord,  diseases  of,  3S0 

leptomeningitis,  403 

meningitis,  403 

muscular  atrophy,  chronic,  411 

pachymeningitis,  chronic,  404 

paralysis,  atrophic,  409 
Spirillum  fever,  289 
Splenic  anemia,  160 
Splenomegalic  polycythemia,  chronic, 

161 
Splenomegaly,  160 
Spotted  fever,  291 

Sputum,  Charcot-Leyden  crystals  in, 
204 

crystals  of  fatty  acids  in,  204 
of  hematoidin  in,  204 

currant-jelly,  203 

Curschmann's  spirals  in,  203 

fetid,  203 

microscopy  of,  203 

mucoid,  203 

mucopurulent,  202 

nummular,  203 

prune-juice,  202 

purulent,  202 

reddish-brown,  203 

rusty,  203 

tubercle  bacilli  in,  204 

with  fibrous  shreds,  203 
Squamous  eczema,  529 
Status  epilepticus,  437 
Steatoma,  485 
Stegomyia  calopus,  325 
Stellwag's  sign,  162 
Stengel's  method  of  drying  and  stain- 
ing blood,  150 
Stenocardia,  193 


Stenosis,  aortic,  182,  183 

mitral,  184 

of  esophagus,  38 

of  pylorus,  58 

of  tricuspid  valve,  186 

pulmonary,  186 
Steorrhea,  482 
Steppage  gait,  368 
Stomach,  absorptive  power  of,  24 

atony  of,  45 

cancer  of,  56 

dilatation  of,  58 

motor  insufficiency  of,  45 
power  of,  24 

neuralgia  of,  50 

round  ulcer  of,  52 

ulcer  of,  perforating,  52 
Stomatitis,  28 

aphthous,  28 

catarrhal  or  simple,  28 

follicular  or  vesicular,  28 

gangrenous,  30 

mercurial,  31 

parasitic,  29 

ulcerative,  29 
Stools,  26 

varieties  of,  26 
Strawberry  tongue,  302 
Stricture  of  bowel,  83 
St.  Vitus's  dance,  444 
Succussion-splash,  214 
Sudamen,  482 
Sunstroke,  460 

Superacidity  of  gastric  contents,  48 
Superficial  veins,  enlargement  of,  468 
Suppurative  encephalitis,  400 
Sweat,  deficiency  of,  480 

excess  of,  480 
Sweat-glands,  diseases  of,  480 
Swimming  in  head,  433 
Sycosis,  512 

parasitica,  536 

simple,  512 
Sydenham's  chorea,  444 
Symmetric  gangrene,  374,  455 
Syncope,  375 

local,  456 
Syphilis  cutanea,  527 
Syphiloderm,  annular,  529 

bullous,  528 

gummatous,  528 


INDEX. 


55? 


Syphiloderm,  macular,  527 

papular,  527 

papulosquamous,  528 

pustular,  529 

tuberculous,  528 
Syringomyelia,  421 

Tabes  dorsalis,  416 
Tache  cerebrale,  381 
Tachycardia,  171 
Taenia  echinococcus,  85 

mediocanellata,  84 

saginata,  84 

sodium,  84 
Tape-worms,  84 
Teeth,  17 

Hutchinson's,  17 
Telangiectasis,  521 
Temperature,  subnormal,  278 
Tertian  fever,  295 

parasite,  295 
Test-breakfast  of  Ewald  and  Boas,  21 
Tetanic  convulsions,  365 
Tetanilla,  454 
Tetanus,  335 

intermittent,  454 
Tetany,  451 
Tetter,  497 
Thermic  fever,  460 
Thermo-anestbesia,  371 
Thoma-Zeiss  hemocytometer,  147 
Thomsen's  disease,  454 
Thoracic  aneurvsm,  195 
Thrill,  168 
Throat,  sore,  35 
Thrombosis,  cerebral,  395 
Thrush,  29 
Tic  douloureux,  447 
Tinea  circinata,  535 

favosa,  537 

sycosis,  536 

tonsurans,  534 

trichophytina,  534 

versicolor,  534 
Tinnitus  aurium,  378 
Titubation,  368 
Tongue,  17 

discoloration  of,  18 

fissures  on,  19 

fur  on,  17 

scars  on,  19 


Tongue,  strawberry,  18,  302 

tremor  of,  18 
Tonsillitis,  acute,  31 
Tonsils,  hypertrophy  of,  34 
Tophi,  346 
Tormina,  65 
Torticollis,  344,  366 
Toxemic  headache,  430 

jaundice,  94 
Tracheal  tug,  195 
Trance,  376 

Traube's  semilunar  space,  209 
Traumatic  dermatitis,  502 
Tremor  of  eyeball,  377 

volitional,  420 
Tremors,  367 
Trichina  spiralis,  87 
Trichiniasis,  87 
Trichinosis,  87 

Tricuspid  valve,  diseases  of,  186 
Trifacial  neuralgia,  447 
Trismus,  335 

Trommer's  test  for  sugar  in  urine,  124 
Trophic  affections  of  hair  and  nails, 

375 
of  skm,  375 
disorders,  456 
Tube-casts,  123 

Tubercle  bacilli  in  sputum,  204 
Tubercles,  476 

Tuberculosis,  acute  general,  327 

miliary,  327 

of  kidney,  144  • 

pulmonary,  257 

Tuberculous  syphiloderm,  528 

Tumor  of  bowel,  83 

of  brain,  396 
Tylosis,  516 
Typhilitis,  78 
Typhoid  fever,  279 
abortive,  283     . 
in  children,  283 
mild,  283 
walking,  283 
septicemia,  280 
Typhus  abdominalis,  279.     See  also 
Typhoid  fever. 
fever,  287 
Tyrosinuria,  120 

Ulcer  of  stomach,  round,  52 


53^ 


INDEX. 


Ulcer,  peptic,  52 

perforating,  of  foot,  374,  480 
of  stomach,  52 

rodent,  529 
Ulceration  from  perverted  nutrition, 

374 
Ulcers,  479 
Uncinaria  duodenalis,  86 

Americana,  86 
Unilateral  atrophy  of  face,  458 
Urates,  120 
Urea,  118 

diminished,  119 

increased,  119 
Uremia,  132 
Uric  acid  diathesis,  347 
Urine,  118 

acetone  in,  127 

albnmin  in,  126 

bile-pigment  in,  129 

blood  in,  127 

chlorids  in,  122 

chyle  in,  129 

diacetic  acid  in,  127 

hematoporphyrin  in,  124 

hemoglobin  in,  128 

indican  in,  128 

leucin  in,  120 

oxalate  of  lime  in,  122 

oxy butyric  acid  in,  127 

phosphates  in,  126 

pus  in,  129 

sugar  in,  124 

suppression  of,  118 

tube-casts  in,  123 

tyrosin  in,  120 

urates  in,  120 

urea  in,  118 

uric  acid  in,  119 

urobilin  in,  124 
Urobilinuria,  124 
Urticaria,  488 

giant,  488 

hemorrhagica,  488 

papulosa,  488 

pigmentosa,  489 

tuberosa,  488 

Vaccination,  313 
Vaccinia,  313 
Vagabondismus,  467 


Valvular  diseases  of  heart,  182 
Valvulitis,  179 
Varicella,  314 

gangraenosa,  315 
Variola,  308.     See  also  Smallpox. 
Varioloid,  311 

Veins,  superficial,  enlargement  of,  468 
Venereal  wart,  518 
Verruca,  518 

acuminata,  518 

digitata,  518 

filiformis,  518 

plana,  518 
Vertigo,  433 

aural,  434 

essential,  434 

labyrinthine,  434 
Vesicles,  472 
Vitiligo,  508 
Vitiligoidea,  524 
Voice,  loss  of,  200 
Volitional  tremor,  420 
Volvulus,  82 
Vomit,  black,  326 

varieties  of,  20 
Vomiting,  20 

Wart,  518 

venereal,  518 
Water  on  brain,  384 
Water     hammer  pulse,  174,  183 
Wen,  485 

Westphal's  contraction,  370 
Wheals,  477 
Whiteness  of  skin,  466 
Whooping-cough,  329 
Word-blindness,  402 
Word-deafness,  402 
Wrist-drop,  465 
Writers'  cramp,  453 
Wry-neck,  344,  366 

Xanthelasma,  524 
Xanthoma,  524 

planum,  524 

tuberosum,  524 

Yellovi^  fever,  325 
Yellowness  of  skin,  466 


Zona,  490 


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